Little by little, ERAS implementation and application in the clinical setting continued growing in the following years until the present. They are not indicated following routine colonic resection above the peritoneal reflection. Background. This is also essential to reducing the risk of venous thromboembolism. Patients undergoing major open colorectal surgery traditionally undergo prolonged rehabilitation and complication rates even as high as 30% have been reported after this procedure [2]. Brief introduction to this section that descibes Open Access especially from an IntechOpen perspective, Want to get in touch? To summarize, we can conclude that published results and their meta-analyses have shown the benefits of this package of measures, so that evidence-based medicine supports the ERAS concept. A diagram with all the core principles of an ERAS program can be seen on Figure 1. ... Wan KM, Carter J, Philp S. Predictors of early discharge after open gynecological surgery in the setting of an enhanced recovery after surgery protocol. This topic will discuss preoperative, intraoperative, and postoperative strategies used in ERAS protocols developed for colorectal surgery. Fluid management can be then optimized using transesophageal monitoring of the cardiac stroke volume with goal-directed administration of fluid boluses. The concept of a “multimodal” approach was first published in 1997 [4] and subsequently prospective studies appeared [5]. In digestive surgery there were some inviolable principles that were transferred between generation of surgeons over a long period of time. Despite the discharge criteria with ERAS programs are similar than in traditional care, patients usually reach these criteria sooner. Raúl Sánchez-Jiménez, Alberto Blanco Álvarez, Jacobo Trebol López, Antonio Sánchez Jiménez, Fernando Gutiérrez Conde and José Antonio Carmona Sáez (March 12th 2014). These kinds of programs are not exclusive of a type of surgery or surgical procedure since they can be applied to different specialties (digestive, vascular, thoracic, etc. Available from: From theory to practice — How to organize an ERAS program, Indication for surgery, information and signed consent, Normothermia: upper-body forced-air heating cover and liquid heater (37ºC), Mask with 4 l/m oxygen flow for 2h independent of saturation, after that nasal cannulae for SpO2 > 95%, Department of General Surgery, Nuestra Señora de Sonsoles Hospital, Ávila, Spain, Department of General Surgery, Santos Reyes Hospital, Burgos, Spain, Physiotherapist, Cadiz University, Cádiz, Spain, Department of General Surgery, University Hospital of Salamanca, Salamanca, Spain. Non-diabetic patients should receive carbohydrate (CHO) loading pre-operatively because they increase glycerol deposits, reduce thirst, hunger and postoperative insulin resistance [14], reducing protein catabolism, postoperative ileus and loss of lean muscle mass. Maintenance of hydration, avoiding overcharge and encouraging the discontinuation of intravenous fluid therapy as soon as possible and early commencement of oral intake, including carbohydrate drinks. Also short-acting anesthetic and analgesic agents should be used, avoiding long-lasting opiates where possible [32]. Drains usage is essential in all kind of digestive procedures. Although most of the studies tend to find a lower morbidity, there are no clear advantage in mortality and we think that more studies are needed to confirm the results and focalized in mortality and long-term results of ERAs methodology. These supplements can be continued beyond the return of normal intake if pre-operative nutritional status is poor. To date our community has made over 100 million downloads. Implementing a Cardiac Enhanced Recovery After Surgery Protocol: Nuts and Bolts. Help us write another book on this subject and reach those readers. The purpose of this study is to analyze the methods and … © 2014 The Author(s). 2019 Mar;32(2):109-113. doi: 10.1055/s-0038-1676475. Reversal of muscle relaxation as needed. Enhanced perioperative nutritional care for patients undergoing elective colorectal surgery at Calvary North Adelaide Hospital: a best practice implementation project. ERAS programs are composed of preoperative, intra-operative and postoperative strategies combined to form a multimodal pathway: Pre-operative optimization: it is focused on targeting areas to optimize patient comorbidities (previous or related to the presenting complaint) such as anemia, diabetic and blood pressure control, optimizing cardiovascular disease treatments, respiratory functioning,…. Perioperative care in colorectal surgery is systematically defined in the Enhanced Recovery After Surgery (ERAS) protocol. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Colorectal Surgery SSI Prevention Bundle and ERAS NYSPFP Webinar Christopher Mantyh, MD Duke University Medical Center. Prophylaxis against thromboembolism with low-dose unfraccionated heparin or low-molecular-weight heparin (grade A recommendation) and the use of elastic stockings or pneumatic compression are recommended. Patients and their families should be very knowledgeable about the process. JBI Evid Synth. Patients undergoing major colorectal surgery under ERP (February 2010 to March 2013) were compared with a traditional care control group (October 2004 October 2007) at a single … The aim of their use is to reduce the dose of general anesthetic needed and the stress response to surgery. In this chapter we will focus on ERAS protocols applied to colorectal surgery. To decrease hospital length stay and a faster patient recovery to normal life. The average compliance improves the longer an ERAS protocol has been active. ( A ) and ( B ). As PhD students, we found it difficult to access the research we needed, so we decided to create a new Open Access publisher that levels the playing field for scientists across the world. Nevertheless, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology. The response to the surgical trauma is protective since his final target is the survival of the disabled organism. Epub 2019 Feb 28. In another colorectal surgery study summarized by Alex Macario, MD, MBA in a 2014 Medscape Viewpoint article, Enhanced Recovery Protocol for Colorectal Surgery, the median length of stay was reduced from seven to five days with the enhanced recovery protocol compared with the traditional group. Medication causing long-term sedation from midnight prior to surgery must not been used, in order to conserve the sleep pattern (grade A recommendation). ERAS protocols are proven to reduce hospital stay safely; however, ERAS pathways may require adaption to ensure both patient and staff safety. Antibiotic prophylaxis with single-dose antibiotic prophylaxis against both anaerobes and aerobes about one hour before surgery is recommended (grade A recommendation). Intravenous opioids are avoided because of increase sedation, ileus and respiratory complications. The aims of Kehlet´s study were to reduce postoperative morbidity and mortality and to promote a faster recovery through a multimodal approach, thus minimizing the impact of the factors that lead to surgical stress. This form (formerly Standard LOR) now includes space on page 3 for a traditional letter for letter writers that prefer the traditional letter. Evidence supporting inclusion of various aspects within the ERAS protocol is briefly reviewed. The confirmation of the initial results should prompt the ERAS methodology embracing in other kind of major surgical procedures as gastric or pancreatic procedures. Epub 2020 Aug 31. Kehlet and colleages were investigating in combined pain relief, early feeding and mobilization since 1995 [4], observing that no more complications were seen and that patients even could be discharged earlier [3]. Enhanced recovery after surgery in colorectal surgery: Impact of protocol adherence on patient outcomes. Definition.  |  •Many features of ERAS protocols are not instantly intuitive and, therefore, pose natural barriers •Current colorectal practice differs greatly from the current available evidence •Adherence rate to ERAS protocols has been shown to be low in the postoperative phase with less than half of patients completing some aspect of postoperative Enhanced Recovery after Surgery (ERAS) refers to patient-centered, evidence-based, multidisciplinary team developed pathways for a surgical specialty and facility culture to reduce the patients surgical stress response, optimize their physiologic function, and facilitate recovery. The success of this program depends on pre-operative setting of expectations including the concept of patients being partners in their care and taking part-ownership of post-operative rehabilitation. The next step was the thinking that some of the improvements seen were simply due to overall changes in perioperative care attitudes. This article presents the specific components of an ERAS protocol implemented at the authors' institution. Contact our London head office or media team here. Targets like postoperative oral intake or early mobilization are given in this stage to the patient. See this image and copyright information in PMC. 1. Surgeons have shown interest in metabolic and endocrine response to the surgical trauma long time ago. ERAS (Enhanced Recovery after Surgery) in Colorectal Surgery, Colorectal Cancer - Surgery, Diagnostics and Treatment, Jim S Khan, IntechOpen, DOI: 10.5772/57136. Other outcome improvements attributed to ERAS programs are shorter duration of postoperative ileus [6], better oral intake, better pain control, less cardiopulmonary morbidity, better preservation of body mass and exercise performance [36], an improvement in grip strength (all of them suggesting an overall improvement in muscular function), earlier resumption of normal activities and a reduced need for daytime sleep [37]. This response also generates adverse effects; some of the most important are: Splanchnic vasoconstriction wich may impact intestinal anastomoses healing. They are associated with discomfort and a delay in oral intake. As a result, a great improvement in postoperative recovery and earlier return of patients to normal function were achieved. The goal of ERAS programs is an accelerated recovery and return to normal activity but it is not the only focus of the protocol [34]. No clear consensus exists regarding the optimal fluid (crystalloid or colloid), the fluid amount (liberal, restricted or supplemental) and the fluid administration (goal-directed fluid therapy by oesophageal Doppler-derived variables –such as stroke volume, the blood volume pumped with each beat- versus conventional haemodynamic variables) for fluid management after and during colectomy. As you may be aware, there currently exists a number of enhanced recovery after surgery (ERAS) protocols in our department. Open Access is an initiative that aims to make scientific research freely available to all. For example, surgeons understood that patients undergoing major open colorectal surgery suffered prolonged rehabilitation with profound changes in endocrine, metabolic, neural and pulmonary function during the postoperative period. The possibility of applying some components of fast-track programs in patients undergoing emergency colorectal surgery must be also evaluated, especially in order to reduce preoperative stress. Early mobilization should occur in accordance with pre-operative plan and is a key element of ERAS in colorectal surgery [10]. This article presents the specific components of an ERAS protocol implemented at the authors' institution. Dexamethasone or 5HT3 receptor antagonist, droperidol or metoclopramide near the end of surgery are recomended. Moreover, it was thought that a minimally invasive approach, with reduced operative trauma, conducted to an earlier return of bowel function and allowed for early oral tolerance. Exhaustion of energy supplies and loss of lean muscle mass, leading to weakness of both peripheral and respiratory muscle if it is severe. 1 Introduction. In particular, details of both surgical and anesthetic ERAS pathways are provided with explanation of all aspects of preoperative, perioperative, and postoperative care. It is necessary to implement all together, because only in this way they demonstrate a greater impact on outcomes than when we implement them as individual interventions [1],[33]. Patients accomplish surgery in the best condition. SURGERY NURSING PATIENT Enter surgery & pre-op orders Enroll in MyChart, Visit ERAS website for information, Patient Education, EMMI videos Prehabiliation: Follow Exercise program, Stoma marking and teaching ... Colorectal ERAS Protocol March 2017.xlsx Created Date: Enhanced recovery after surgery (ERAS) programs are evidence-based protocols designed to standardize and optimize perioperative medical care. CHOP developed an Enhanced Recovery after Surgery (ERAS) protocol for children who undergo total nephrectomy for Wilms tumor.The standard of care for children with Wilms tumor includes total nephrectomy - a major abdominal operation that is nevertheless usually technically straightforward and well tolerated. A checklist is provided for clinicians to easily reference and facilitate implementation of a standardized protocol. The aim is to reduce muscle loss and improve respiratory function, reducing the risk of pneumonia, and maximizing oxygen delivery to tissues. Conclusions and Relevance Enhanced Recovery After Surgery is an evidence-based care improvement process for surgical patients. We want to highlight the one from Rahbari et al [25]. Children’s Hospital of Philadelphia. It’s based on principles of collaboration, unobstructed discovery, and, most importantly, scientific progression. Regarding hospital discharge, factors such as pain, lack of gastrointestinal function and immobility complications are the main delaying patient discharge after colorectal surgery. ERAS Protocol for Colorectal Surgery Reduces Complications, LOS An ERAS program for the colorectal surgical population, implemented by a research team at Vanderbilt University Medical Center, was associated with significantly reduced complication rates, a >1.5-day reduction in length of stay and reduced total hospital costs of over 20 percent. D’Souza K, Choi JI, Wootton J, Wallace T. Can J Surg. Pre-operative nutritional management: drinks and any new medication and nutritional supplements should be given at this time. J Obstet Gynaecol Res 2016;42:1369–74. 3.1 Acetaminophen 1000 mg given orally every 6 hours for 72‐96 hours (Level of evidence: Low) 3.2 Prescription Post‐operative celecoxib 400 mg initial dose followed by 200 mg bid for 5 days is recommended in patients having a colorectal resection where NO anastomosis is performed (for example, abdominal perineal resection) and where no contraindications to its use are present. Contemporary colorectal surgery is often associated with long length of stay (8 days for open surgery and 5 days for laparo- scopic surgery),3high cost, and rates of surgical site infec- tion approaching 20%.4During the hospital stay for elective colorectal surgery, the incidence of perioperative nausea and vomiting (PONV) may be as high as 80% in patients with certain risk … Postoperative serious hypotension may best treated with vasopressors rather than large quantities of intravenous fluids. DOCUMENT CHO drink (Clearfast) was taken and document time 3. “All of them went home in less than three days, and in one case, one day, which is not the norm, but very exciting to see.” Authors included nine randomized controlled trials, finding that restrictive fluid amount (OR 0.41 with 95% CI 0.22 to 0.77; P = 0.005) and goal-directed fluid therapy by means of oesophageal Doppler-derived variables (OR 0.43 with 955 CI 0.26 to 0.71; P = 0.001) significantly reduced overall morbidity after colorectal resection compared with standard fluid amount and fluid therapy guided by conventional haemodynamic variables respectively. It is preferred those medication that have a minimal post-operative hang-over and effects on gastrointesinal motility. It is very important to make them a partner in the process and give them the responsibility for their recovery and they should be clearly informated about the perioperative care, normal course of the protocol, discharge criteria, possible complications and the outpatient follow-up after discharge. Mechanical and oral antibiotic bowel preparation instructions. This methodology can improve outcome (patients recovered gut function significantly faster and suffered significantly less gastrointestinal and overall morbidity) in patients with significant medical comorbidities allowing an earlier hospital discharge [23]. This site needs JavaScript to work properly. ... -IDENTIFY ERAS patients for protocol participation-DIET begins night of surgery-AMBULATION begins night of surgery-HOB at 30 degrees at all times-IVF