This is really a variation of the “fast track” protocols that have been in existence since the early 1990s, with some more specific emphasis on nutritional and pain management elements. It is designed to improve outcomes by approaching elective surgical procedures from a multidisciplinary approach throughout the “stages” of the patient’s surgery: pre-hospital, in house, and post-discharge. It includes some things that we already do (like trying to get patients mobilized early), as well as some things that we won’t be able to do in the near future (routine thoracic epidurals). It also includes some things we might be able to do betterà pain management, nutrition, fluid management, etc. Note again this is for elective surgery, not our emergent trauma cases.
The name most associated with ERAS is Olle Ljungqvist; if you Google him, you’ll find a bunch of articles on the subject. The protocol has been in existence since 2002, and there is a good review of it in Clinical Nutrition 2005 Vol 24(3): 466-477. Two additional sources you might want to look at are in Archives of Surgery May 2011 Vol 146(5): 571-577; and Archives of Surgery Oct 2009 Vol 144(10): 961-969. This latter article has the ERAS group’s recommendations and the levels of evidence they assign to them. The original ERAS data was developed in patients with need for colorectal surgery, but has been expanded in Europe to include all GI surgery in the centers that have adopted it.
The full protocol is long, but to summarize an example from one ERAS center:
1. Preop
a. Bowel preparation- phosphate enemas only for patients undergoing left sided colon resections; no preps for other patients
b. Nutrition- patients able to eat solids until six hours before planned surgery and liquids until 2 hours before surgery. There is some commercial bias, as the authors use a solution called PreOp (also called Nutricia) that is patented, but the principle is that carbohydrate loading preoperatively enhances early post op bowel recovery
c. Prophylaxis- some type of heparin prophylaxis started the day before surgery
d. Admission- the patients were in some centers admitted the day before; we probably won’t be able to do that here (not much longer anyway)
2. Inta op
a. Anesthesia - patients received thoracic epidurals as well as general anesthesia; lidocaine and sufentanil given initially, followed by periodic bupivocaine but no further opioids.
b. Antibiotics given similarly to our SCIP protocols
c. Normothermia maintained throughout the case
d. Hypotension treated preferentially with phenyleprhine vs IV fluids (this again is an elective case, not the large volume hemorrhage seen in our emergent cases in which blood products would be used preferentially)
e. Very selective use of drains; removal of NG tubes post op (since they go to almost immediate oral feeds [see below] the feeding access would not be needed)
3. Post op
a. Ondansetron administered routinely at the end of operation
b. Patient immediately allowed to drink water and if tolerated started on the PreOp/Nutricia formulation ( 2 drinks).
c. POD 1 patient given normal diet
d. IVF used to maintain 0.5ml/kg/hr urine output not to exceed 2 liters /24h
e. Structured mobilization program (some protocols have OOB 2 hours post op, with 6 hours daily starting POD1; others have variations on this)
f. Continued pain management with epidural catheter, acetaminophen and NSAIDS, with opioids only for breakthrough (of course we can’t do routine epidurals )
g. Removal of urinary catheter on the day of removal of thoracic epidural
Although it is not part of the ERAS protocol per se, Dr. Ljungqvist had endorsed the work of Dr. Juan Ochoa, who takes the nutrition part of the protocol even further. In the Journal of the American College of Surgeons 2011 Vol 212(3): 385-399, Drs. Ochoa, Drover (lead author), Weitzel, Wischmeyer, and Heyland present a meta-analysis of randomized clinical trials evalutating arginine-supplemented diets in ELECTIVE surgical patients (there is other data for trauma in particular). Their conclusion was that these diets were associated with fewer infectious complications, particularly even given both pre- and post-op. Note that these diets contained not just arginine, but other nutrients as well, specifically omega-3 fatty acids and anti-oxidants. When Dr. Ochoa speaks on this subject, he is clear that it is probably the combination of nutrients that gives the best results; they act in concert. In a recent talk he suggested 5 days of preoperative targeted nutrition therapy for elective GI surgery patients.
Anyway, some things to think about.
from Dr. Kimberly Joseph
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