LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’...

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Luisito O. Llido Professorial Lecture Nutri&on and Recovery a1er Surgery Olle Ljungqvist MD PhD Professor Surgery Örebro University Hospital & Karolinska InsEtutet Sweden PHILSPEN Manilla, The Phillipines October 7, 2014

Transcript of LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’...

Page 1: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Luisito  O.  Llido  Professorial  Lecture      

Nutri&on  and  Recovery  a1er  Surgery    

Olle  Ljungqvist  MD  PhD  Professor  Surgery  

Örebro  University  Hospital  &  Karolinska  InsEtutet  Sweden  

PHILSPEN Manilla, The Phillipines

October 7, 2014

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Recovery  AIer  Surgery  What  are  we  trying  to  achieve?  

Pa&ent  back  to  preopera&ve  func&on  •  Normal  gastrointes&nal  func&on  

–  Normal  food  intake  –  Bowel  movement  

•  Pain  control  •  Mobility  

•  No  complica&on  

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What  is  ERAS?  

•  ERAS  =  Enhanced  Recovery  AIer  Surgery  •  Consensus  on  perioperaEve  care*  •  InternaEonal  network  –  ERAS  Society  •  Team  work  –  mulE  professional  &  disciplinary  •  ImplementaEon:    

– Audit  – Control  over  care  

*Fearon  et  al,  Clin  Nutr  2005,  Lassen  et  al,  Arch  Surg,  2009,  Guidelines  2012,2013,2014  www.erassociety.org  

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History  

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Ann Surg. 2002 Nov;236(5):643-8. From Cuthbertson to ERAS: 70 years of progress in reducing stress in surgical patients. Wilmore DW.

Sir David Cuthbertson, UK Francis Moore, USA

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Henrik  Kehlet:  concepts  

•  Epidural anaesthesia

•  Multimodal approach to recovery

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Highlights: 2001: Initiation 2003: Database 2005: 1st protocol 2006: Implementation 2009: 2nd protocol

Tromsö:  A  Revhaug  

Stockholm:  O  Ljungqvist  

Copenhagen:  H  Kehlet  

Maastricht:  M  v  Meyenfeldt,  C  deJong  

Edinburgh:  KFC  Fearon  

Growth: St Marks: R Kennedy Nottingham: D Lobo Charité: C Spies, A Fledheiser

ERAS Study Group!

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ERAS  

Epidural Anaesthesia

Prevention of ileus/

prokinetics

CHO - loading/ no fasting

Early mobilisation

Peri-op fluid management

DVT prophylaxis

Pre-op councelling

Short acting anesthetics

No - premed

No bowel prep

Perioperative Nutrition

Body heating devises

Oral analgesics/ NSAID’s

Incisions

No NG tubes

Early removal of catheters/drains

Fearon  et  al,  Clin  Nutr  2005  

Page 9: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

A Non profit Multi-professional Multi-disciplinary Medical Society Founded in 2010

Mission statement: Enhancing Recovery After Surgery The mission of the Society is to develop perioperative care and to improve recovery through •  Research, •  Education, •  Audit and •  Implementation of evidence based practice.

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The  paradigm  shi1:    

Mul&  modal    Mul&  professional  Mul&  disciplinary  

 EBM  in  prac&ce:  Implementa&on  

Interac&ve  Team  Audit  Large  network  in  collabora&on  

   

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Philosophy  

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ERAS  Philosophy:  The  paEent’s  journey  

CLINIC                          PRE-­‐OP  

POST-­‐OP                WARD                                HOME                      

RECOVERY  

SURGERY  /  ANESTHESIA  

InteracEve  Team  audit  of  outcomes  &  compliance  

PRE  ADMISSION

FOL  LOW    UP    30  D  AY  

Integrated  ERAS  protocol  

Ljungqvist  JPEN  2014  

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ERAS  team  approach  

•  Surgeon  •  Anesthes&st  •  HDU  specialist  •  Ward  nurses  •  Anesthesia  nurses  •  Physiotherapist  •  Die&&an  

•  Management  

Team  work:  •  Training  •  Implemen&ng  •  Planning  •  Audi&ng  •  Upda&ng  •  Repor&ng  •  Research  

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ERAS  Securing  modern  care  

Surgeon:  No  bowel  prep  Food  a1er  surgery  No  drains    Early  removal  u-­‐catheter  No  iv  fluids,  no  lines  Early  discharge  All  evidence  based!  

Anesthe&st:  

Carbohydrates  no  fas&ng  

No  premedica&on  

Thoracic  Epidural  Anesthesia  (open)  

Balanced  fluids  

Vasopressors  

No  or  short  ac&ng  opioids    

Page 15: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ERAS  works!  

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ERAS  Meta  analys  

ERAS:  shorter  length  of  stay  by  2.5  days  

Varadhan  et  al,  Clin  Nutr  2010    

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ERAS  Meta  analys  

ERAS:  Reduce  complicaEons  by  50%  

Varadhan  et  al,  Clin  Nutr  2010    

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How?  

Page 19: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ERAS  

Epidural Anaesthesia

Prevention of ileus/

prokinetics

CHO - loading/ no fasting

Early mobilisation

Peri-op fluid management

DVT prophylaxis

Pre-op councelling

Remifentanyl

No - premed

No bowel prep

Perioperative Nutrition

Bairhugger

Oral analgesics/ NSAID’s

Incisions

No NG tubes

Early removal of catheters/drains

Fearon  et  a  al  2005,  Lassen  et  al  Arch  Surg  2009  

Page 20: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

3  new  guidelines  2012  

Page 21: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ERAS  in  Theory  

Page 22: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Goals  Back  to  normal  food  Energy  and  protein  

   2  Key  targets:  Gut  working  

Metabolism  ready        

Page 23: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Goals  Back  to  normal  food  Energy  and  protein  

   2  Key  targets:  Gut  working  

Metabolism  ready  ERAS  does  both!  

     

Page 24: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Goals  Back  to  normal  food  Energy  and  protein  

   2  Key  targets:  Gut  working  

Metabolism  ready        

Page 25: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

The Metabolic Stress Response to Surgery and Trauma

Page 26: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

The Metabolic Stress Response to Surgery and Trauma

Page 27: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  &  Recovery  Insulin:  main  anabolic  hormone  involved  in  •  All  parts  of  metabolism  

–  Glucose  control  –  Fat  metabolism  –  Protein    

•  Regulator  of  return  of  key  func&ons  •  Central  to  development  of  complica&ons  •  Affected  by  many  periopera&ve  treatments  

 

Page 28: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  &  Recovery  Insulin:  main  anabolic  hormone  involved  in  •  All  parts  of  metabolism  

–  Glucose  control  –  Fat  metabolism  –  Protein    

•  Regulator  of  return  of  key  func&ons  •  Central  to  development  of  complica&ons  •  Affected  by  many  periopera&ve  treatments  

•  Insulin  resistance:  a  key  for  understanding  and  enhancing  recovery  

•  Insulin  func&on  key  for  anabolism  

Page 29: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

PostoperaEve  Insulin  resistance  

Defin&on:  Below  normal  metabolic  effect  of  insulin  •  Glucose  uptake    •  Reduc&on  in  glucose  produc&on  •  Lipolysis  •  Protein  breakdown  /  balance  

   

Page 30: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  sensiEvity  falls  with  the  magnitude  of  surgery  

Adopted  from  Thorell  et  al:  Curr  Opin  Clin  Nutr  Metab  Care  1999  

-­‐80  

-­‐70  

-­‐60  

-­‐50  

-­‐40  

-­‐30  

-­‐20  

-­‐10  

0  Lap  chol   Open  hernia   Open  chol   Open  colorectal  

Reduc&on  in  Insulin  Sensi&vity  (%)  

Postop

 /  Preo

p  M-­‐value

 x  100

 (%)  

P  <  0.001,  ANOVA  n  =  6-­‐13  

More  Insulin    

Resistance  

Preop  level  

Page 31: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

                               Postop        Type  2  DM  

Hyperglycemia          +        +  

Insulin  sensiEvity        -­‐        -­‐    

Glucose  produc&on      +        +  

Peripheral  glucose  uptake  -­‐        -­‐  

GLUT4  translocaEon      -­‐          -­‐  

Glycogen  formaEon        -­‐          -­‐  

 

 Adopted  from  Ljungqvist  et  al,  Clin  Nutr  2001  

Driving  forces  for  hyperglycemia  aIer  surgery  similar  to  diabetes  

Page 32: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Normalizing  insulin  acEon  normalizes  metabolism  

Insulin  infusion  to  normalize:    •  Blood  glucose  Also  controlled:  •  FFA    •  Urea  excre&on  •  Substrate  u&liza&on  a1er  major  surgery  Insulin  resistance  the  key  to  catabolism  

Brandi LS et al: Clin Sci 1990

Page 33: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Independent  factors  predicEng  length  of  stay  

•  Type  of  surgery  

•  Periopera&ve  blood  loss    

•  Postopera&ve  insulin  resistance  

R2  =  0.71,  p  <  0.01  

Thorell  et  al:  Curr  Opin  Clin  Nutr  Metab  Care  1999  

Page 34: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Glucose  uptake    -­‐  stress    

Fat  

Liver  

Kidney  

Blood  cells  

Endothel  Neural  &ssue  

Insulin  regulated  Concentra&on  regulated  

[Glucose]  Muscle  

Too  liqle  

Too  much  

Page 35: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  resistance  muscle  

•  Reduced  glucose  uptake  

•  Reduced  glycogen  storage  

•  Increased  protein  catabolism  

 

Page 36: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  resistance  muscle  

•  Reduced  glucose  uptake  

•  Reduced  glycogen  storage  

•  Increased  protein  catabolism  

 

Lean  body  mass  

Muscle  func&on  

Mobilisa&on  

Energy  supply  

Page 37: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Impaired  Recovery  

Postop  (days)          Tissues/cells    Muscle  weakness      muscle  Infec&ons          leukocytes  Cardiovascular        blood  vessels  Renal  failure        kidney  Polyneuropathy      nerve  &ssue  

Page 38: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Glucose  uptake    -­‐  stress    

Fat  

Liver  

Kidney  

Blood  cells  

Endothel  Neural  &ssue  

Insulin  regulated  Concentra&on  regulated  

[Glucose]  Muscle  

Too  liqle  

Too  much  

Page 39: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ComplicaEons  

Postop  (days)          Tissues/cells    Infec&ons          leukocytes  Cardiovascular        blood  vessels  Renal  failure        kidney  Polyneuropathy      nerve  &ssue  Muscle  weakness      muscle  

Page 40: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

PostoperaEve  insulin  resistance  increase  the  risk  for  complicaEons  

The  ORs  were  adjusted  for  potenEal  confounders  

Complica&on   OR  for  every  decrease  by    1  mg/kg/min  

(≈  25%  reduc&on  in  Insulin  sensi&vity)  

P  value  

Death   2.33  (0.94-­‐5.78)   0.067  

Major  complicaEon   2.23  (1.30-­‐3.85)   0.004  

Severe  infecEon   4.98  (1.48-­‐16.8)   0.010  

Minor  infecEon   1.97  (1.27-­‐3.06)   0.003  

Sato  et  al,  JCEM    2010;  95:  4338-­‐44  

273  paEents  open  cardiac  surgery,  insulin  sensiEvity  determined  at  the  end  of  op  

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ERAS  

Epidural  Anaesthesia  

Preven&on  of    ileus/  prokine&cs  

Preop  CHO/  no  fas&ng  

Early    mobilisa&on  

Peri-­‐op  fluid  balance  

DVT    prophylaxis  

Pre-­‐op  councelling  

Short  ac&ng    anaesthe&cs  

No  -­‐  premed  

No  bowel  prep  

Early  postop  oral  feeding  

Maintaining  body  temperature  

Oral  analgesics/  NSAID’s  

Surgical  technique  

No  NG  tubes  

Early  removal  of  catheters/drains  

Fearon  et  al,  Clin  Nutr,  2005  

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ERAS  

Epidural  Anaesthesia  

Preven&on  of    ileus/  prokine&cs  

Preop  CHO/  no  fas&ng  

Early    mobilisa&on  

Peri-­‐op  fluid  balance  

DVT    prophylaxis  

Pre-­‐op  councelling  

Short  ac&ng    anaesthe&cs  

No  -­‐  premed  

No  bowel  prep  

Early  postop  oral  feeding  

Maintaining  body  temperature  

Oral  analgesics/  NSAID’s  

Surgical  technique  

No  NG  tubes  

Early  removal  of  catheters/drains  

Fearon  et  al,  Clin  Nutr,  2005  

Page 43: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ERAS  elements  to  reduce  insulin  resistance  

Preopera&ve  •  Preopera&ve  carbohydrates  •  Epidural  anesthesia  

Postopera&ve  •  Pain  control  •  Early  postop  feeding        

Page 44: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Change  from  fasted  to  fed  using  a  Carbohydrate  load  

Aims:  Insulin  response    •  20%  glucose  iv    •  12.5%  carbohydrate  drink  400  ml  2  h  before  anesthesia  

         –  many  studies  combined  with  800  ml  in  the  evening  before  

Page 45: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Semng  before  surgery  

                             Fasted            CHO  fed  Hyperglycemia            -­‐                      (+)  Insulin  sensiEvity                          -­‐                    +50%    Glucose  produc&on                  +                      -­‐  -­‐  -­‐  Peripheral  glucose  uptake    -­‐                      +++  GLUT4  translocaEon        -­‐                      +++  Glycogen  formaEon                      -­‐                      +++      

Adopted  from  Ljungqvist  et  al,  Clin  Nutr  2001  &  Svanfeldt  et  al  Clin  Nutr  2005  

Page 46: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Gastric  emptying  is  complete  in    90  minutes  for  CHO  &  water  

Nygren  et  al,  Ann  Surg,  1995  

Minutes  a1er  intake    

Isotop

e  ac&v

ity  in    

the  stom

ach  (%

)  

120  90  60  30  0  0  

20  

40  

60  

80  

 100  

 120  **  

*  

*  

*  

CHO,  n=6      

Water,  n=6  

Page 47: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Safety  data    Preop  CHO  rich  drink  

•  >5,000  pa&ents  in  clinical  studies  in  surgical  pa&ents  

•  150  pa&ents  before  gastroscopy  •  >3,000,000  pa&ents  in  surgical  prac&ce  

•  No  adverse  events  reported  

Page 48: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Why  give  preop  carbohydrates?  

•  Effec&vely  reduce  insulin  resistance  

•  Improves  well  being  

•  Improves  postopera&ve  muscle  func&on  

•  Reduce  lean  body  mass  losses  

•  May  result  in  faster  recovery  

Page 49: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Preopera&ve  CHO  reduces    postop  insulin  resistance  

-60

-50

-40

-30

-20

-10

0

10

20

Cholecystectomy Colorectal Arthroplasty Arthroplasty

Per c

ent c

hang

e fr

om p

reop

* * * *

*P < 0.05

Nygren  et  al:  Curr  Opin  Clin  Nutr  Metab  Care  2001  

CHO Control

More    resistance  

Page 50: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Confusing  data  No  effect  of  preop  carbs?  

Page 51: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Clamp  ≠  HOMA  

Baban et al, Clin Nutr 2014 in press / on line

Page 52: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Whole  body  glucose  disposal  

0  

1  

2  

3  

4  

5  

6  

7  

8  

Basal   Low   High  

WGD  (m

g  min-­‐1  kg-­‐1)   Preop  

Postop  *  

Nygren  et  al,  Clin  Sci  1996  

P-­‐Insulin              10                                                            30                65  µU/ml  

HOMA  

Clamp  

Page 53: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Preop  Carbohydrates  acEvates  muscle  insulin  signalling  pathways  

0  

200  

400  

600  

800  

1000  

1200  

Control   Placebo   Carbohydrate  

PI3Kinase    (units)   p=0.02

Wang  et  al,  BJS  2010  

Page 54: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Preop  Carbohydrates  maintains  postop  muscle  anabolic  pathways  

P<0.001

Wang  et  al,  BJS  2010  

0  

0.01  

0.02  

0.03  

0.04  

0.05  

0.06  

Carbohydrates   Placebo   Control  

Protein  Tyrosine  Kinase  Ac&vity  

Page 55: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

PreoperaEve  carbohydrates  retains  lean  body  mass  (MAC)  

Yuill  et  al,  Clin  Nutr  2005  

P <0.05

[cm]

Page 56: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

0

1

2

3

4

5

6

Urea  losses  (m

mol/kg/d)

PreoperaEve  carbohydrates  reduces  protein  losses  and  improves  muscle  

strength  

P<0.05  

-­‐16 -­‐14 -­‐12 -­‐10 -­‐8 -­‐6 -­‐4 -­‐2 0

Postop

era&

ve  m

uscle  strength  (%

)

Control CHO

P<0.05  Mean  (SEM)  

Crowe, BJS 1984; Henriksen Acta Anaesth Scand 2003

Urea losses Muscle strength

Page 57: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Breuer et al, Anesth Analg, 2006

Preop carbohydrate reduces requirements of inotropic support in cardiac surgery

Page 58: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Preoperative effects oral CHO

Main subjective Preop discomforts* Effect CHO vs placebo°

Thirst no difference Hunger reduced Anxiety reduced Insomnia not determined

°J  Hausel  et  al,  Anesth  &  Analg  2001  *M Madsen et al, J Perianaesth Nurs 1998

Page 59: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

All  recent  Guidelines  recommend  oral  carbohydrate  treatment  Germany  2003:  Major  surgery        Anaesthesist.  2003  Nov;52(11):1039-­‐45.    

Scandinavia  2005:  Major  surgery  Acta  Anaesthesiol  Scand.  2005  Sep;49(8):1041-­‐7    

ESPEN  2005:  Major  surgery    Clin  Nutr.  2006  Apr;25(2):224-­‐44    

ESPEN  2009:  Major  surgery  Clin  Nutr.  2009  May  20    

United  Kingdom  2009:  ElecEve  surgery    J  Intensive  Care  Society.  2009;10(1):13-­‐5    

European  Soc  Anesthesiol  2011:  ElecEve  surgery  Eur  J  Anaesthesiology.  2011;28:556-­‐569      

Page 60: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Eur  J  Anaesthesiology.  2011;28:556-­‐569    

PreoperaEve  carbohydrates  

Page 61: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Preop  carbs  shorter  length  of  stay  

*Awad  et  al,  Clin  Nutr  2012  

Page 62: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Preop  carbs  shorter  length  of  stay  

Smith  JD  et  al,  Cochrane  library  2014  

Page 63: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Preop  carbs  shorter  length  of  stay  

Smith  JD  et  al,  Cochrane  library  2014  

Page 64: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Combining  carbohydrates  with  other  stress  reducing  treatments  

 

Page 65: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Combining  carbohydrates  with  other  stress  reducing  treatments  

=  Enhanced  Recovery  AIer  Surgery  

   

Page 66: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ERAS  

Epidural Anaesthesia

Prevention of ileus/

prokinetics

CHO - loading/ no fasting

Early mobilisation

Peri-op fluid management

DVT prophylaxis

Pre-op councelling

Remifentanyl

No - premed

No bowel prep

Perioperative Nutrition

Bairhugger

Oral analgesics/ NSAID’s

Incisions

No NG tubes

Early removal of catheters/drains

Lassen  et  al,  Arch  Surg,  2009  

Page 67: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

EDA  reduces  postoperaEve  insulin  resistance  

Uchida,  Br  J  Surg  1988    

-­‐100

-­‐50

0

50

100

150

200

250

300

350

Epinephrine Cor&sol Insulin  sensi&vity

Postop

era&

ve  cha

nge  (%

)

IV  Opiates EDA *p<0.05 **p<0.01

* * **

Page 68: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

EDA  +  PreoperaEve  CHO  to  control  glucose  during  enteral  feeding    

Soop  M  et  al,  Br  J  Surg,  2004;  *Harrison  et  al,  JPEN  1997  

0.0!

1.0!

2.0!

3.0!

4.0!

5.0!

6.0!

7.0!

8.0!

9.0!

10.0!Gl

ucos

e (m

mol

/l)!

Day!

complete!

hypocaloric!

Traditional*

No  insulin  required  

Page 69: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  sensiEvity  improved  with    pre  op  Carb,  EDA  +  post  op  feed  

From  Thorell  et  al:  Curr  Opin  Clin  Nutr  Metab  Care  1999,  Soop  M  et  al,  Br  J  Surg,  2004  

-­‐80  

-­‐70  

-­‐60  

-­‐50  

-­‐40  

-­‐30  

-­‐20  

-­‐10  

0  Lap  chol   Open  hernia   Open  chol   Open  colorectal  

Post  op  change  in  Insulin  Sensi&vity  (%)  

Postop

 /  Preo

p  M-­‐value

 x  100

 (%)  

More  Insulin    

Resistance  

Preop  level  

CHO  EDA  Postop  Feed  

Page 70: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Goals  Back  to  normal  food  Energy  and  protein  

   2  Key  targets:  Gut  working  

Metabolism  ready        

Page 71: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

EDA  vs.  Iv  opiates  

Jorgensen  Cochr  Database  Syst  Rev  2004  

Epidural  –  avoiding  opioids  Less  paralysis  

Page 72: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ERAS:  oral  intake  development    (mean  intake  postop  day  1-­‐4)  

Page 73: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Energy  intake  ±  ONS  aIer  liver  resecEon  

Hendry  et  al,  BJS  2010  

Page 74: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Bowel  movement  aIer  liver  resecEon  

Hendry  et  al,  BJS  2010  

LaxaEon  –  1  day    LaxaEon  +  ONS  vs  control  ONS  –  1  day      3  (3-­‐4)                                vs    6  (4-­‐7)                  p=  0.013  

Page 75: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ERAS  in  the  old  and  co-­‐morbid                                                                                                

           Early  ERAS  /      ERAS                2002-­‐2004  /    2005-­‐2006    

<  75  years                          n=    160  /        164  >  74  years,  ASA  1-­‐2,                    n=                  89      /            50  >  74  years,  ASA  3-­‐4                  n  =                34    /            33    

Thus,  39%  over  75  years    Colonic  resecEon    J  Nygren,  Ersta  hospital  personal  communicaEon  

Page 76: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

FuncEonal  recovery    Colonic  resecEon  

012345678

P1 P2 P1 P2 P1 P2 P1 P2 P1 P2

Pos

top

days

, med

ian

<75>74 ASA 1-2>74 ASA 3-4

                             Flatus                  Bowels                            Food                  Drip  down        Mobile  6h  

Page 77: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  sensiEvity  Day  before  surgery  Insulin

 sensitv

ity  

Bowel  prep  No  nutri&on  

Dinner,  normal  sleep  

ERAS  Care  

Tradi&onal  care  

Page 78: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  sensiEvity    Morning  of  surgery  Insulin

 sensitv

ity  

Bowel  prep  No  nutriEon  

Dinner,  normal  sleep  

Carbohydrate  treatment  

Overnight  fas&ng  

ERAS  Care  

Tradi&onal  care  

Page 79: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  sensiEvity    Anesthesia  start  

Insulin

 sensitv

ity  

Bowel  prep  No  nutriEon  

Dinner,  normal  sleep  Carbohydrate  treatment  

Overnight  fasEng  

Thoracic  Epidural  

Preopera&ve  seda&on  

ERAS  Care  

Tradi&onal  care  

Page 80: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  sensiEvity    ReacEon  to  surgery  Insulin

 sensitv

ity  

Bowel  prep  No  nutriEon  

Dinner,  normal  sleep  Carbohydrate  treatment  

Overnight  fasEng  

Thoracic  Epidural  

PreoperaEve  sedaEon  

Surgery  

Greater  drop  without  Epidural  

ERAS  Care  

Tradi&onal  care  

Page 81: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  sensiEvity    AIernoon  of  surgery  Insulin

 sensitv

ity  

Bowel  prep  No  nutriEon  

Dinner,  normal  sleep  Carbohydrate  treatment  

Overnight  fasEng  

Thoracic  Epidural  

PreoperaEve  sedaEon  

Surgery  

Immediate  feeding  &  mobilisa&on  

NPO  iv  low  caloric  fluids  

ERAS  Care  

Tradi&onal  care  

Page 82: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  sensiEvity    Days  aIer  surgery  

Insulin

 sensitv

ity  

Bowel  prep  No  nutriEon  

Dinner,  normal  sleep  Carbohydrate  treatment  

Overnight  fasEng  

Thoracic  Epidural  

PreoperaEve  sedaEon  

Surgery  

Immediate  feeding  &  mobilisaEon  

NPO  iv  low  caloric  fluids  

Oral  feeding  &  mobilisa&on  

Slow  return  to  feeding  and  mobilisa&on  Days  -­‐  weeks  

ERAS  Care  

Tradi&onal  care  

Page 83: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Insulin  sensiEvity    Days  aIer  surgery  

Insu

lin s

ensi

tvity

Bowel  prep  No  nutriEon  

Dinner,  normal  sleep  Carbohydrate  treatment  

Overnight  fasEng  

Thoracic  Epidural  

PreoperaEve  sedaEon  

Surgery

Immediate feeding & mobilisation

NPO  iv  low  caloric  fluids  

Oral feeding & mobilisation

Slow  return  to  feeding  and  mobilisa&on  Days - weeks

ERAS  Care  

Traditional care

Ljungqvist  JPEN  2012  

Page 84: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Gut  working  

•  Avoiding  opioids  

•  Fluid  balance  

•  Chewing  gum  3  Emes  daily  

•  LaxaEves    

Page 85: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

October 14, 2014 Olle Ljungqvist 85

Slower  gastric  emptying  and  bowel  movements  

Overloading with fluids and salt reduces GI motility

Lobo  D,  Lancet  2002:  359;  1812-­‐1818  

Passage of gas: 2 days faster; stools: 3 days faster

Body weight Gastric emptying

Page 86: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Chewing  gum:  flatus  8h  sooner  

Li  S  et  al,  J  Gastroenterol  Hepatol.  2013  Jul;28(7):1122-­‐32    

Page 87: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Chewing  gum:    bowels  move  0,5d  sooner  

Li  S  et  al,  J  Gastroenterol  Hepatol.  2013  Jul;28(7):1122-­‐32    

Page 88: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Chewing  gum:  shorter  length  of  stay  

Li  S  et  al,  J  Gastroenterol  Hepatol.  2013  Jul;28(7):1122-­‐32    

Page 89: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Chewing  gum  in  benign  gynecology  

Jerrigan  AM  et  al  Int  J  Gyn  Obst,  2014  in  press  

Page 90: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

LaxaEves  in  hysterectomy  

Hansen  CT  et  al,  AJOB  2007;  196  

Bowel  movement  laxaEves  45h,  controls  69h,  p<0.001,  n=  53    

Page 91: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

LaxaEves  in  colectomy?  

Andersen  et  al  Colorect  Dis  2011;  14;  776  

Bowel  movement  laxaEves  42h,  controls  50h,  p>0.15  (n=22/27)    

Page 92: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ERAS  guideline  2014:  Gastrectomy  

Colon  

Pancreas  

Rectal  

Page 93: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ERAS  compliance:  Length  of  stay  &  Readmissions    

Gustafsson  et  al,  Arch  Surg  2011  

n = 953 p < 0.05

Compliance with ERAS protocol elements Single center study consecutive patients

Colorectal cancer

Page 94: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ERAS  compliance:  ComplicaEons  

Gustafsson  et  al,  Arch  Surg,  2011  

n = 953 p < 0.05

0"

5"

10"

15"

20"

25"

30"

35"

40"

45"

50"

<50%" >70%" >80%" >90%"

Complica6ons"

Compliance with ERAS protocol elements Single center study, consecutive patients

Per

cen

t pat

ient

s af

fect

ed

Colorectal cancer

n  =  953  P  <  0.05  

Page 95: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Reduced  mortality?  

Savaridas  et  al,  Acta  Orthopedica  2013:  84,  40-­‐43  

Hip  and  Knee  replacement    TradiEonal    AIer  implementaEon  of  ERAS    Causes  of  death  Higher  for  Trad:  Malignant  disease        

Page 96: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

ERAS  Compliance:  LOS  in  open  colonic  resecEons  

N=  57  own  cases  (green  dot),  compared  to  934  total  cases  in  15  other  centers  

Page 97: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Recovery  –  what  does  it  mean?  

Lee  et  al,  Surgery  2014  

Page 98: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

3rd  World  Congress  of    ERAS®  Society  with  American  Society  for  Enhanced  Recovery  Evidence  Based  PerioperaEve  Medicine  UK    ERAS  Society  introductory  course  Henrik  Kehlet  lecture  ERAS  Society  lecture  ERAS  Society  guidelines  ERAS  for  the  surgeon  

 the  anesthesiologist      the  nurse        the  manager  

New  findings  –  abstracts  Debates  Workshops  

www.erassociety.org  

Page 99: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Summary:  NutriEon  &  ERAS  

Gut  working  •  Avoid  opioid  induced  gut  paralysis  •  Keep  fluids  in  balance  •  Food,  ONS  combined  for  energy  and  protein  •  +  laxa&ves  for  even  faster  gut  recovery  •  Chewing  gum  Metabolism  ready  •  Minimize  insulin  resistance  Combining  ERAS  elements  for  best  results  

Page 100: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Summary:  NutriEon  &  ERAS  

Gut  working  •  Avoid  opioid  induced  gut  paralysis  •  Keep  fluids  in  balance  •  Food,  ONS  combined  for  energy  and  protein  •  +  laxa&ves  for  even  faster  gut  recovery  •  Chewing  gum  Metabolism  ready  •  Minimize  insulin  resistance  Combining  ERAS  elements  for  best  results  

Ge{ng  metabolism  and  nutri&on  right  is  key  in  ERAS  

Page 101: LuisitoO. Llido’Professorial’Lecture’’. Llido’Professorial’Lecture’’ ’ Nutri&on)and)Recovery)a1er)Surgery’) Olle’LjungqvistMD’PhD’ Professor Surgery’ Örebro’University

Stockholm  winter  

Stockholm  winter  


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Enhanced Recovery After Surgery (ERAS) – Implementation ... · 8/14/2019  · • Enhanced Recovery After Surgery (ERAS): Implementation Challenges and Successes –Baptist Health

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ENHANCED RECOVERY AFTER SURGERY PROTOCOLS Recovery After... · 2015-02-17 · Enhanced Recovery After Surgery Protocols Annual Queenstown Update in Anaesthesia, 2012 72 72 Figure

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