AAGBI Enhanced Recovery Seminar April 2010

Anaesthesia, Goal Directed Therapy and Enhanced Recovery for Colorectal Surgery
Thursday 22 April 2010 Organisers: Dr Mike Scott & Dr William Fawcett, Guildford
Programme: Introduction & overview A national perspective Ann Driver, Director, NHS Improvement, Dr Martin Kuper, National Advisor, ERPP Overview of enhanced recovery in open and laparoscopic colorectal surgery Dr Mike Scott, Guildford Fluid management for open and laparoscopic colorectal surgery Dr Howard Wakeling, Worthing Analgesia for open and laparoscopic surgery Dr William Fawcett, Guildford Focus on laparoscopic colorectal procedures: Improving the perioperative care pathway Dr Patrick Morgan, Redhill Implementing enhanced recovery in your unit Dr Roger Kipling, Yeovil
AAGBIMeeting22ndApril2010 OverviewofEnhancedRecoveryinColorectalSurgery
DrMikeScott RoyalSurreyCountyNHSFoundationTrust,Guildford
EnhancedRecovery(ER)isnowestablishedasamodalitythatcanbeusedtoreducethelengthofstayandmorbidity aftermajorsurgery.ItwasestablishedbyKehletandcolleaguesaspartoftheERAS(EnhancedRecoveryAfter Surgery)groupinScandinaviaandisbeingadoptedandimplementedacrosstheUKbytheDepartmentofHealth.It isbasedaround17pointsofcaretominimiseinterventionandreturnthepatientsbacktoindependenceand mobilitywithincreasingoraldiet.SomeUKcentres,includingours,haveuseditforthelast4yearswithincreasing success. LaparoscopicColorectalsurgeryisideallysuitedforERaspatientscaneatanddrinkaftersurgeryandtheSIRS responseisalsoalotmorelimitedcomparedtoupperGISurgery. WehavesimplifiedtheapproachtoEnhancedRecoverybydeliveringmostoftheERcomponentsbyprotocolbut takingoutthefluid/oxygendeliveryandanalgesiccomponents.Wefeelthesearethemostimportantindividual componentstoachieveasuccessfuloutcomeapartfromthesurgeryitselfandaredeliveredbytheanaesthetist.
Simplified Enhanced Recovery in Laparoscopic Colorectal Surgery Trimodal Model

Scott Fawcett Levy Rockall
Enhanced Recovery Protocol
Individualised Fluid Therapy Effective Analgesia
Early Mobility
Early Gut Function
Modulation of stress response

Early Mobility
Early Gut Function
Decreased Complications Healing
Decreased Length of Stay
Thesecomponentscombinedwithearlymobilityleadtoearlyfeedingandgutfunction.Thisinturnhelpsto modulatethestressresponseandpromoteshealing.Reducedcomplicationsandsecondaryinfectionleadtoa decreasedlengthofstay.
Analgesia Therehasbeenmuchcontroversyovertheoptimalanalgesicmodalityinlaparoscopiccolorectalsurgery.Most groupsacceptedtheconceptthatEpiduralAnalgesiawhichwasaprovenbenefitinopensurgerywouldbe transferrabletolaparoscopicsurgery.Wehavenotfoundthisso.Shortdurationofinpatientstayhasbeen successfulbygroupsusingmorphine.Ourcarefullypractiseduseofspinalanalgesiacombinedwithgeneral anaesthesiahasleadtoareproducible23hourstay.OurexperiencewithepiduralsinanRCTwithOesophageal Dopplerguidedfluidshasshownpatientswithepiduralsaremoreimmobile,receivemorefluidandhavealonger timetobowelfunctionandhospitaldischarge. FluidsandOxygenDelivery Laparoscopicsurgeryisnotwithoutitsownproblems.Complexsurgery,lengthofsurgeryandbleedingcanalllead toincreasedlengthofstay.WebelieveindividualisedfluidtherapyusingOesophagealDoppler(OD)isoneofthe mostimportantstrategiestobeadoptedbyanaesthetistaswellusingmodernanaesthetictechniques.Our haemodynamicstudieshaveshownareductioninoxygendeliveryduringlaparoscopicsurgeryduetoincreased aorticafterloadwhichwebelieveisdetrimentalincertainpatientgroupssuchastheelderlyandthosewithco morbidity.Thiscanbeexaggeratedfurtherbythesteepheaddownpositioncommoninalotoflaparoscopic colorectalprocedures.UnlessODisusedinthesegroupsandoxygendeliveryoptimisedduringandattheendofthe proceduresomeofthebenefitsofhavingminimallyinvasivesurgeryarenegatedbyanoxygendeficitandsplanchnic hypoperfusion.
Outcome
ShortinpatientsstaysutilisingERandminimallyinvasivesurgeryhasbeenshowntobesafewithgoodpatient satisfaction.Withpatientselectionandoptimalcare23hourstayisachievable.Twotofourdaysismoreusualfor ourpatients,particularlythosewhoareelderlyorwithcomorbidities.Ourpatientfollowupoutcomehas demonstratedanimproved5yearmortalitywhencomparedtonationalfiguresbyupto30%foranequivalent Dukesstagecancer.ItisunclearexactlywhythereisthisbenefitbutIfthisimprovementinoutcomeis substantiatedthenperioperativecareusingenhancedrecoveryandminimallyenhancedsurgeryshouldbenow viewedasanimportanttreatmentstrategyincancer.
KeyReferencesforFasttrackColorectalSurgery
1. DelaneyCP.Outcomeofdischargewithin24to72hoursafterlaparoscopiccolorectalsurgery.DisColonRectum2008;51(2):181 185. 2. KehletH.Randomizedcontrolledtrialtoexaminetheinfluenceofthoracicepiduralanalgesiaonpostoperativeileusafter laparoscopicsigmoidresection.BrJSurg2000;87(3):379. 3. KehletH.Postoperativeileusanupdateonpreventivetechniques.NatClinPractGastroenterolHepatol2008;5(10):552558. 4. LassenK,SoopM,NygrenJ,CoxPB,HendryPO,SpiesC,vonMeyenfeldtMF,FearonKC,RevhaugA,NordervalS,LjungqvistO,Lobo DN,DejongCH.Consensusreviewofoptimalperioperativecareincolorectalsurgery:EnhancedRecoveryAfterSurgery(ERAS)Group recommendations.ArchSurg2009;144(10):961969. 5. LevyBF,ScottMJ,FawcettWJ,RockallTA.23hourstaylaparoscopiccolectomy.DisColonRectum2009;52(7):12391243. 6. NoblettSE,SnowdenCP,ShentonBK,HorganAF.RandomizedclinicaltrialassessingtheeffectofDoppleroptimizedfluid managementonoutcomeafterelectivecolorectalresection.BrJSurg2006;93(9):10691076. 7. WakelingHG,McFallMR,JenkinsCS,WoodsWG,MilesWF,BarclayGR,FlemingSC.IntraoperativeoesophagealDopplerguidedfluid managementshortenspostoperativehospitalstayaftermajorbowelsurgery.BrJAnaesth2005;95(5):634642. 8. http://www.18weeks.nhs.uk/content.aspx?path=/achieveandsustain/Transformingandimproving/enhancedrecovery/ 9. LevyB,DowsonH,ScottM,StonehamJ,FawcettW,ZuleikaM,RockallT.TransoesopagealDopplerassessmentofthe haemodynamicchangesoccurringduringlaparoscopiccolorectalsurgery.BJS2008;95(S3):57 17
Overview of Enhanced Recovery In Colorectal Surgery
Enhanced Recovery Partnership Programme
Cancer Action Team
Dr Mike Scott
FRCP FRCA
Consultant in Anaesthesia and Intensive Care Medicine Royal Surrey County NHS Foundation Trust and St Lukes Cancer Centre Guildford UK
http://www.18weeks.nhs.uk/
Name Mrs Teresa Moss Professor Roger Motson Mr Tan Arulampalan Sr Jane Hendricks Professor Tim Rockall Dr Mike Scott Dr Bill Fawcett Mr Alan Horgan Mr Charles MaxwellArmstrong Mr Austin Acheson Mr Robin Kennedy Ms Astra Tertullien Mr Omar Faiz Mr Mark Coleman Mr Nader Francis Mr Jonathan Ockrim Dr Roger Kipling Sr Louise Evans Dr Fiona Carter
Job Title Director Consultant Colorectal Surgeon Consultant Colorectal Surgeon Theatre practitioner/ ER coordinator Consultant Colorectal Surgeon Consultant Anaesthetist Consultant Anaesthetist Consultant Colorectal Surgeon Consultant Colorectal Surgeon Consultant Colorectal Surgeon Consultant Colorectal Surgeon ERP Programme Co-ordinator
Organisation National Cancer Action Team Colchester General Hospital/ ICENI Colchester General Hospital/ ICENI Colchester General Hospital/ ICENI Royal Surrey County Guildford / MATTU, Royal Surrey County Guildford / MATTU, Royal Surrey County Guildford / MATTU, Freemantle Hospital, Newcastle Queens Medical Centre, Nottingham Queens Medical Centre, Nottingham St Marks Hospital, North West London Hospitals NHS Trust St Marks Hospital, North West London Hospitals NHS Trust St Marks Hospital, North West London Hospitals NHS Trust
Lap. Colorectal NTP Lead Consultant Colorectal Surgeon Consultant Colorectal Surgeon Consultant Colorectal Surgeon Consultant Anaesthetist Senior Ward Sister Course Development Manager
Plymouth Hospitals NHS Trust Yeovil District NHS Foundation Trust Yeovil District NHS Foundation Trust Yeovil District NHS Foundation Trust Yeovil District NHS Foundation Trust Yeovil District NHS Foundation Trust
MATTU Guildford, University of Surrey National and European Laparoscopic Training Centre
National Directive
Laparoscopic Colorectal Procedures where possible E h Enhanced R d Recovery Training for Surgeons and ER Team (Retraining)
Prof Tim Rockall, Mr Iain Jourdain, Research Fellows: Bruce Levy , Andy Day Dr Bill Fawcett, Dr Mike Scott, Dr John Stoneham
Example of enhanced recovery elements

Referral from Primary Care
Optimising pre operative haemoglobin levels Managing pre existing co morbidities e.g. diabetes Admission on day Optimised Fluid Hydration CHO Loading Reduced starvation No / reduced oral bowel preparation ( bowel surgery)
Why is Colorectal surgery well suited to an ER program?
PreOperative
Admission
Optimised health / medical condition Informed decision making Pre operative health & risk assessment PT information and expectation managed DX planning (EDD) Pre-operative therapy instruction as appropriate
Minimally invasive surgery Use of transverse incisions (abdominal) No NG tube (bowel surgery) Use of regional / LA with sedation Epidural management (inc thoracic) Optimised fluid management Individualised goal directed fluid therapy
IntraOperative
Planned mobilisation Rapid hydration & nourishment Appropriate IV therapy No wound drains No NG (bowel surgery) Catheters removed early Regular oral analgesia Paracetamol and NSAIDS Avoidance of systemic opiate-based analgesia where possible or administered topically
PostOperative
DX when criteria met Therapy support (stoma, physio) 24hr telephone follow up
Colorectal surgical procedures are well subscribed and reproducible due to modern technology (staple guns etc) limited SIRS response limited, unlike complex upper GI Provided no complications then patients recover quickly (HOW QUICKLY?)
Follow Up
7
23 Hour Stay Laparoscopic Colectomy
Enhanced Recovery
Denmark Kehlets Group Open surgery Produced backbone of work around which has formulated h h f l t d enhanced recovery d 20 points Reduced length of stay dramatically
Levy BF, Scott MJ, Fawcett WJ, Rockall T, 23-hour-stay laparoscopic colectomy. [Controlled Clinical Trial, Journal Article] Trial Dis Colon Rectum 2009 Jul; 52(7):123943.
Enhanced Recovery Model
Key points
Pre-operative Patient Education / Expectation Setting targets for the patients Avoiding interventions that upset normal body homeostasis: NGT Modern anaesthesia Fluid management Analgesia Thoracic Epidural Early oral intake Early mobilisation
Enhanced Recovery
Pre-op education Avoidance of bowel preparation Pre-operative carbohydrate drink Avoidance of pre-op sedatives Thoracic epidural started before skin incision Upper body air heating cover Avoidance of abdominal drains Avoidance of NGT Intra-op fluid less than 3000 mls At least 800 mls orally on day 0 At least 1 nutritional supplement on day 0 pm At least 2 nutritional supplement on day 1 Termination of iv fluids on day 1 Termination of urinary drainage on day y g y 2 Solid food eaten on day 1 Aperient given Mobilisation on the day of surgery Mobilise at least 6 hours on day 1 Post-operative thoracic epidural Termination of thoracic epidural on day 2 (48hours)
Enhanced Recovery

Pre-op education Avoidance of bowel preparation Pre-operative carbohydrate drink Avoidance of pre-op sedatives Thoracic epidural started before skin incision Upper body air heating cover Avoidance of abdominal drains Avoidance of NGT Intra-op fluid less than 3000 mls At least 800 mls orally on day 0 At least 1 nutritional supplement on day 0 pm At least 2 nutritional supplement on day 1 Termination of iv fluids on day 1 Termination of urinary drainage on day y g y 2 Solid food eaten on day 1 Aperient given Mobilisation on the day of surgery Mobilise at least 6 hours on day 1 Post-operative thoracic epidural Termination of thoracic epidural on day 2 (48hours)
Operative Day
Oral carbohydrate drink upto 2 hours before surgery No bowel prep No sedative pre-med Spinal or Thoracic epidural before surgery Operation laparoscopic, no drains Oesophageal Doppler to guide fluids Cefuroxime & metronidazole (+ 2 post op doses) Avoid NGT Keep patient warm Cup of tea in recovery Hartmanns 8 hourly then 16 hourly then down Nutritional supplement before bed time Clexane
Day by Day Summary
Day 1
Up and mobilise (4 walks per day) Urinary catheter out Nutritional supplement 16 hrly IV Hartmanns to complete then down Oral analgesia Further nutritional supplement Onto oral fluids
Day 2
Increase mobility (If Epidural take out & take Urinary Catheter out) O l food and d i k Oral f d d drink Oral analgesia
Challenging established concepts

Groups around the UK are challenging the established concepts in open surgery of: 1) Pain relief using alternatives than epidural analgesia: Spinal Pain buster TAP Block 2) How long to keep patients in hospital 3) The importance of reducing the stress response
Key Points for optimal outcome from major open surgery

Patient selection Patient optimisation Surgical technique Perioperative fluid optimisation (global, local) Oxygen delivery (periop / 12 hours post op) Optimal analgesia to improve function Early mobility Early return of gut function Prophylaxis against secondary complications Early detection and treatment of complications
Enhanced Recovery Model

Enhanced Recovery Protocol
Individualised Fluid Therapy Effective Analgesia
Early Mobility
Early Gut Function

Analgesia: Open v Laparoscopic

Epidural has been recognised as the gold standard for open surgery Usually run for 48-72 hours Analgesic adjuncts necessary There has been as assumption in the medical world that epidurals will give the same advantages in patients undergoing Laparoscopic surgery
Early Mobility
Early Gut Function
Decreased Complications Healing
Decreased Length of Stay
RCT Completed
Levy BF, Scott MJ, Fawcett WJ, Rockall T
Anaesthetic Technique
Oral Preload Propofol / Alfentanil / Rocuronium Air / Oxygen / Sevoflurane Remifentanil / Phenyepherine Spinal or Epidural or Morphine Oesophageal Doppler Guided Colloid Post op Hartmanns 8, 16 hourly finish Oral paracetamol / voltarol / tramadol
3 groups 102 patients Epidural v spinal v morphine All received Oesophageal Doppler guided fluids within Enhanced recovery protocol Endpoints Fluids & vasoconstrictors used, weight gain Respiratory function and mobility LOS, morbidity, mortality Patient satisfaction, QWALYs
Summary of Work
Spinal group best in recovery 10% of spinal group needed morphine in recovery morphine rescue increases with length of operation S i l and morphine group similar at 24 h Spinal d hi i il t hours Respiratory function similar in all groups O2 delivery better in patients with spinal / epidural Epidural group received around 2 litres more fluid, gained 2kg, were slower to mobilise and eat and stayed in 2 more days
Laparoscopic colorectal surgery

Key differences
Intraoperative cardiopulmonary stresses may be greater DO2 may be reduced during laparoscopy DO2 is reduced compared to open surgery with an p p g y epidural Our haemodynamic work suggests this is due to increased aortic afterload Spinals and epidurals can increase DO2 Steep head down/up can effect neuroaxial blocks
Minimally Invasive Surgery Maximum cardiopulmonary stress
Laparoscopic colorectal surgery

Key differences
Bowel handling is minimised Abdominal incision is smaller, transverse and below the umbilicus SIRS response is different Analgesic requirements at 12 - 24 hours can usually be addressed with oral analgesics
48 Hours Post-Op
Which is the optimal stress response?
Epidural group in hospital
Spinal group at home
Inclusion criteria
Levy BF, Scott MJ, Fawcett WJ, Rockall T, 23-hour-stay laparoscopic colectomy. [Controlled Clinical Trial, Journal Article] Dis Colon Rectum 2009 Jul; 52(7):123943. 1. Colonic or high rectal procedure 2. ASA 1 3. Age< 65 4. BMI< 28 5. Adequate home support 6. Competent adult present for 24 hours after discharge 7. Telephone line/mobile 8. Home< 10 miles from Hospital 9. Incision< 7 cm 10. Agreement with GP 11. Uncomplicated operation
Method
Admitted on day of surgery Oral Preload 800ml night before 400mls 2 -3 hours before surgery Standard surgical technique GA plus spinal anaesthesia
Anaesthetic Technique
Sitting awake spinal 2.5mls Hyperbaric Bupivicaine 0.5% with Diamorphine 0.25% Induction: Propofol / Alfentanil / Rocuronium (Central venous line used to measure post op ScvO2) Fluid optimisation using oesophageal Doppler prior to insufflation IPPV O2 / Air / Sevoflurane (Remifentanil Infusion) / Phenypherine as needed
Follow up
All patients phoned on the first night after surgery 24 hour contact number Any problem present to A+E Then follow up in clinic three days later Routine follow up All patients happy with pathway All would choose it again
Discharge Criteria
patient has good pain control on oral analgesics patient is independently mobile, reached pre-op level patient takes solid foods IVI down foods, all 3 criteria reached patient willing to go home / has support at home
Perioperative care Pathways
ERAS results by age
3 Groups of Patients: No co morbidities Major co morbidities Elderly (with or without co-morbidities)
What perioperative factors make patients deviate off care pathway and increase Length of Stay?
In Patient Care Pathways
Length of time of surgery important: 1. surgeons experience 2. difficulty of operation / mobilisation of bowel 3. teaching Bleeding Failure of Analgesia Early post-operative vomiting
ER - Whats it all about?

Reduced length of stay Reduced morbidity Reduced perioperative mortality R d d i ti t lit Reduced perioperative costs
70 60 50 40 30 20 10 0
Whats it really all about: survival
Colon Column2 Rectum Column3
80-89
70-79
60-69
50-59
40-49
15-39
Does enhanced recovery and laparoscopic surgery have the potential to improve the outcome from cancer?
Hypothetical Reasons Laparoscopic surgery / Enhanced Recovery may effect the immune system differently E l review of our series d Early i f i demonstrates patients t t ti t receive chemotherapy at least 22 days earlier than open surgery
Summary
Patients still need pre-assessment and optimisation Rapid recovery depends on the anaesthetist focusing on a Trimodal approach : 1. Delivering the components of Enhanced Recovery 2. Individualised fluid therapy using Oesophageal Doppler and li iti post operative IV fl id D l d limiting t ti fluids 3. Effective analgesia Early discharge is safe provided the right back up is in place Perioperative care should now be considered as important a cancer treatment as other treatment options e.g. chemotherapy
48 Hours Post-Op
Which is the optimal stress response?
Epidural group in hospital
Spinal group at home
Perioperativefluidadministrationforabdominalsurgery: liberalorrestrictiveregimen?.
Dr. Peter Isherwood MBChB MRCP FRCA Specialist Registrar Anaesthesia & ICM Western Sussex Hospitals NHS Trust Worthing Hospital Lyndhurst Road Worthing BN11 2DH Dr. Howard G. Wakeling MB.BS, BSc, MRCP (UK), FRCA Consultant Anaesthetist Western Sussex Hospitals NHS Trust Worthing Hospital Lyndhurst Road Worthing BN11 2DH +44 1903 285151 Direct Line +44 1903 286786 Fax Correspondence to: Dr. Wakeling howard.wakeling@wsht.nhs.uk
Summary
There is a plethora of published work regarding pre, peri and postoperative fluid management and as a whole they present the clinician with a confusing picture. The circulation has been assessed peri-operatively over the years with heart rate, blood pressure, central venous pressure and even invasively with the pulmonary artery catheter. Recently a range of alternative and less invasive technologies have been developed to measure cardiac output in the operating room and critical care settings. These include oesophageal and suprasternal Doppler ultrasound, calibrated and uncalibrated pulse contour methods, use of the Fick principle, aortic impedance monitoring and the use of central venous oxygen saturation. There are many comparative studies some demonstrating benefit others not. The specific nature of the control group treatment in each of the studies and the reproducibility of the results is vitally important when considering how to best use this enormous quantity of data. Consequently we find advocates of various fixed dose fluid regimens, restricted fluids, liberal fluids, arterial line based stroke volume variation and pulse pressure variation. However only stroke volume optimisation with oesophageal Doppler, targeted oxygen delivery (DO2I) with the pulmonary artery catheter and the avoidance of fluid overload have a significant evidence base demonstrating improved outcome.
In the 1970s the advent of the pulmonary artery catheter made possible the measurement of cardiac output monitoring and oxygen delivery in the clinical setting. Using a goal directed approach in the management of high-risk surgical patients using a target (DO2I) of 600ml.min.m2, Shoemaker demonstrated a significant improvement in outcome. Importantly this improvement was repeated in two further studies by Boyd and by Wilson1 giving a strong overall evidence base for this technique. Interestingly Wilson was able to report that targeted colloid fluid made the most significant contribution to improved outcome in the treatment groups rather than the inotropic agents as most patients were reaching target or were close to target using fluid alone. Since the pulmonary artery catheter a range of alternative and less invasive technologies have been developed to measure cardiac output in the operating room and critical care settings. These include oesophageal and suprasternal Doppler ultrasound, calibrated and uncalibrated pulse contour methods, use of the Fick principle, aortic impedance monitoring and the use of central venous oxygen saturation. The oesophageal Doppler monitor or ODM (CardioQ, Deltex Medical, Chichester, UK) has the most supporting evidence of all these devices. Doppler ultrasound directly measures the velocity of blood flow in the aorta allowing stroke volume and other flow related variables to be accurately measured. The accuracy of these measurements is minimally affected by the large changes in cardiovascular compliance that occur during anaesthesia and surgery. The principle behind Doppler guided stroke volume optimisation is the prevention of hypovolaemia and gut hypoperfusion which may occur in approximately 60% of major surgery patients 2. In addition Noblett3 showed stroke volume optimisation reduced the stress response in colorectal surgery patients by demonstrating a reduction in blood Interleukin-6 levels, an inflammatory cytokine associated with increased complications. Stroke volume optimisation is achieved by the giving of a colloid fluid challenge usually 200-250ml (but could be less), looking for a rise in stroke volume of 10%. If such a rise occurs then it is assumed that the patient is on the rising part of the Starling curve and a further bolus is given. This process is continued until the stroke volume fails to rise after fluid. No further fluid is then given until the stroke volume falls. This approach treats occult and overt hypovolaemia whilst protecting against fluid overload. It has been shown to prevent gut hypoperfusion and the adverse outcomes associated with it giving improved outcome2. A recent meta-analysis of Goal-directed haemodynamic therapy supports the importance of avoiding peri-operative splanchnic hypoperfusion and its associated GI complications in major surgery4. The fluid management system may be represented in a flow chart format, Figure 1. Randomised controlled trials have demonstrated a reduced length of hospital stay in patients undergoing colorectal surgery, cardiac surgery and orthopaedic surgery. To date all properly conducted clinical studies involving the ODM have demonstrated an improved outcome in the ODM treated patients and the evidence further strengthened by 3 independent meta-analyses such as that by Phan5. There are three systems which use various analyses of the arterial waveform to estimate stroke volume and cardiac output. Two of these are linked to a calibration system based on trans-pulmonary tracer dilution, and two are not calibrated. The LiDCO, (LiDCO Ltd, Cambridge, UK) uses lithium dilution to calibrate the PulseCO system which then tracks changes in the circulation by analysing the pressure wave from the radial artery. In order to gain best precision, 3 calibrations are performed at each time and these must be performed every 4 to 8 hours or after any major
change in the circulation. Unfortunately, both depolarising and non-depolarising muscle relaxants may interfere with the lithium calibration. LiDCO has been demonstrated to reduce length of stay and complication rates of surgical patients when used to target DO2I in intensive recovery following major surgery with only standard intra-operative anaesthesia care6. However a further similar study from the same group presented at the ECISM meeting this year involving 135 post-operative patients did not reproduce the clinical benefit despite demonstrating apparent circulatory improvements. Similarly the PiCCO (Pulsion Medical Systems, Munich) system uses a dilution calibration for its pulse contour analysis algorithm. This time thermodilution is performed using cold saline into a large peripheral or central vein and the signal is picked up by a thermistor tipped arterial line in a proximal artery which then calibrates a pulse contour analysis system. Due to the difficulty of calibration in an operating room setting LiDCO have developed a non-calibrated PulseCO system which works from the arterial line alone the LiDCO Rapid and similarly the FloTrac device (Edwards Lifesciences, Irvine, California, USA) also monitors the circulation from uncalibrated arterial line analysis. These devices can be used to watch estimated stroke volume trends or may be used to predict fluid responsiveness by looking at variations in stroke volume or pulse pressure over the respiratory cycle, so called SVV and PPV. The principle is that hypovolaemia causes a variation in the stroke volume and pulse pressure of ventilated patients like the swing seen on an arterial wave form. In this way a SVV or PPV value over a certain percentage predicts fluid responsiveness and indicates that the anaesthesiologist perhaps should give or below this threshold fluid should not be given. There are many studies trying to find the best cut-off value for SVV and PPV (mostly between 8% and 15%). In order to follow these trends in a patient must have stable ventilator settings and it cannot be used in spontaneously breathing patients. Despite many studies demonstrating the phenomenon of fluid responsiveness using SVV or PPV there has only been one study demonstrating a benefit in patient outcome. Lopes7 used a non-commercially available PVV system intra-operatively (using 10% as the cut off) to measure fluid responsiveness. He did show reduced complications and improved outcome but there has been great concern over poor fluid management of the control group. High risk patients undergoing major surgery received an average of only 1600ml crystalloid and without colloid fluids. A recent intraoperative study using the LiDCO calibrated PulseCO with a pulse pressure variation of 10% to predict fluid responsiveness, aiming to improve renal function and organ failure score following emergency abdominal surgery failed to demonstrate any benefit8 over a relatively well treated control group. The arterial waveform analysis systems available; PiCCO and Flotrac have been compared with LiDCO and each other and found to demonstrate a good correlation in their measurement of cardiac output in stable situations. However acute variations in arterial blood pressure, as occur frequently in the operating room have been shown to affect the reliability of the Flotrac9. At the International Update in Haemodynamic Monitoring meeting in Rome in December 2009 there was much concern and discussion amongst key opinion leaders regarding the relative advantages and disadvantages of the calibrated versus non-calibrated arterial line based systems. Overall the experts considered calibrated systems were too cumbersome for the operating room but there was concern that the non-calibrated systems were not accurate enough for intensive care patients.
It is of vital importance that the concept of Stroke Volume Optimisation as measured by Oesophageal Doppler is not confused with the predicted fluid responsiveness from SVV or PPV concept. They are clearly not the same. Indeed a recent study evaluated the ability of the FloTrac arterial pulse contour analysis stroke volume variation (SVV) to predict fluid responsiveness and referenced it against stroke volume changes measured by the ODM10. It found that the Flotrac could not serve as a predictor of fluid response during major abdominal surgery. Indeed the predictive value of Flotrac for SVV was only 0.5, equal to the tossing of a coin. That the two concepts are not the same helps to explain why there are a large number of trials in major surgery showing outcome benefit for patients with Doppler guided stroke volume optimisation but no consistent outcome benefit has been demonstrated in studies from the use of SVV or PPV estimates of fluid responsiveness. There is much interest in central venous oxygen saturation as a guide to fluid administration during surgery. In emergency surgery patients who are extremely ill the ScvO2 can be useful in guiding overall haemodynamic care but it is less useful in the elective surgery patient. This is because the intra-operative ScvO2 remains in the normal range for this patient group and changes relatively little (when compared with stroke volume changes for instance), making it very difficult to target therapy with. The concept of fluid restriction came into prominence after research from Denmark by Brandstrup. This multicentre trial demonstrated that a restrictive peri-operative fluid regimen improved outcome in major surgery patients. However as with all of the comparative fluid studies a careful look at the control group reveals relatively large volumes of sodium rich intravenous fluid given to patients in this group. So terms such as fluid restriction or liberal fluids are not helpful and it is perhaps better to conclude that the avoidance of salt and fluid overload is a more accurate description for the mechanism of improvement in Brandstrups patients than fluid restriction per se. The avoidance of administering large quantities of sodium rich fluids during and after major surgery when the stress response is avidly retaining salt and water has been demonstrated by many others. Excessive fluid administration is known to slow the gut recovery and lead to a higher incidence of complications. A particularly thorough recently published peri-operative fluid consensus guideline document, the GIFTASUP12 guidelines describes in great detail the pathophysiology of excessive fluid administration during and after major surgery and the effects of the stress response. It is very interesting to note that Doppler guided intra-operative stroke volume optimisation in the studies usually involved only small quantities of additional colloid fluid administration mostly around 500ml and one showed no overall additional fluid was required at all3. So it is clear that the advantage of avoiding intraoperative hypovolaemia with stroke volume optimisation is completely compatible with avoiding fluid overload if excessive crystalloid administration is prevented. This combination is recommended by the GIFTASUP consensus guidelines and forms the basis of many Enhanced Recovery Programmes. Indeed this approach is used in the Worthing Enhanced Recovery programme. Oesophageal Doppler guided stroke volume optimisation usually involves between 500ml and 1250ml colloid only for major surgery. Patients receive little or no post-operative intravenous fluid as they start oral fluids immediately. Recently the NHS National Technology Adoption Centre placed oesophageal Doppler into 3 major UK hospitals for use in a wide variety of major surgery patients, including major orthopaedics. They then compared patient outcomes with recent
case matched controls prior to implementation. Overall there was a 67% reduction in mortality, 4 day reduction in length of stay, 23% reduction in central line use, 33% reduction in readmission rate, 25% reduction in re-operation rate and a large reduction in critical care length of stay. These results can be viewed at www.technologyadoptionhub.nhs.uk. Previously Pulmonary artery catheter DO2I targeting and now oesophageal Doppler Stroke Volume Optimisation must now be considered the gold standard for intraoperative fluid management because of the significant, consistent evidence base. Only when the use of other technologies and SVV/PPV fluid responsiveness have been robustly compared against these standards in well conducted randomised clinical studies can they be accepted as equivalent. In summary, fluid management strategies for major surgery include Stroke Volume Optimisation with Oesophageal Doppler guided colloids, SVV or PPV fluid responsiveness and stroke volume trending with arterial waveform analysis, aiming for a DO2I target using a pulmonary artery catheter, and fluid restriction to avoid salt and water overload. Only the pulmonary artery catheter, oesophageal Doppler and the avoidance of fluid overload have a significant evidence base clearly demonstrating improved patient outcome after major surgery. Both stroke volume optimisation and DO2I target based strategies are fully compatible with the avoidance of fluid overload by accurate targeting of colloid fluid boluses and avoiding excessive unnecessary crystalloid administration.
References 1. Wilson J, Woods I, Fawcett J, Whall R, Dibb W, Morris C, McManus E. Reducing the risk of major elective surgery: randomized controlled trial of preoperative optimization of oxygen delivery. Br Med J 1999; 318: 1099103.
Example of classic research paper using pulmonary Artery Catheter to target oxygen delivery in major surgery patients.
2.Mythen MG, Webb AR. Intra-operative gut mucosal hypoperfusion is associated with increased post-operative complications and cost. Intensive Care Med 1994; 20: 99104
This research showed the frequency of poor splanchnic circulation during major surgery and the improvement seen with stroke volume optimization preventing occult hypovolaemia.
3. Noblett SE, Snowden CP, Shenton BK, Horgan AF Randomised clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. British Journal of Surgery 2006; 93:1069-1076.
Randomised controlled trial of Doppler guided colloid fluid therapy in colorectal patients showing improved outcome, reduced IL-6 stress response but with no overall additional fluid.
4.M. T. Giglio, M. Marucci, M. Testini and N. Brienza. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. British Journal of Anaesthesia 103 (5): 63746 (2009)
Meta-analysis looking specifically at gastrointestinal complications after major surgery and the improvements achieved by using goal directed fluid therapy either with the Pulmonary artery catheter or the oesophageal Doppler.
5. Phan TD, Hilmy I, Heriot AG, Ho KM, Improving Perioperative Outcomes: Fluid Optimization with the Esophageal Doppler Monitor,a Metaanalysis and Review. J. Am. Coll. Surgeons 2008; Vol. 207, No. 6: 935 941.
Meta-analysis of oesophageal Doppler guided stroke volume optimisation in surgical patients. It demonstrates the consistent improvement in outcome seen with the use of the technology.
6. .Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Rupert Pearse, Deborah Dawson, Jayne Fawcett, Andrew Rhodes, R Michael Grounds and E David Bennett. Critical Care 2005, 9:R687-R693 (DOI 10.1186/cc3887)
This study demonstrated outcome benefit from using LiDCO in postoperative major surgery patients in an intensive recovery setting.
7. Lopes M, Oliveira M, Pereira V, et al. Goal directed fluid management based on pulse pressure variation monitoring during high risk surgery: A pilot randomized controlled trial. Crit Care 2007; 11 ; R100
This study showed an improvement in outcome in high risk surgical patients using PPV. However questions have been raised over the fluid management of the control group.
8. J. Harten, J.E.M. Crozier, B. McCreath, A.Hay, D.C. McMillan, C.S. McArdle, J. Kinsella. Effect of intraoperative fluid optimisation on renal function in patients undergoing emergency abdominal surgery: A randomised controlled pilot study. International Journal of Surgery 6 (2008) 197-204
This study compared LiDCO PPV fluid management with a reasonably well managed control group in colorectal patients and did not show an outcome benefit.
9. S Eleftheriadis et al. Variations in arterial blood pressure are associated with parallel changes in FlowTrac / Vigileo (R) derived cardiac output measurements: a prospective comparison study. Critical Care 2009, 13: R179
This study demonstrated how it is possible for large changes in blood pressure affect the cardiac output estimation by the FloTrac. This is of particular importance as the device is not calibrated and blood pressure and circulatory compliance change frequently and markedly during anaesthesia and surgery.
10. D. Lahner, B. Kabon, C. Marschalek, A. Chiara, G. Pestel, A. Kaider, E. Fleischmann and H. Herz. Evaluation of stroke volume variation obtained by arterial pulse contour analysis to predict fluid responsiveness intraoperatively. British Journal of Anaesthesia 103(3): 346-51 (2009)
This study helps to demonstrate that SVV fluid responsiveness is not the same as Doppler guided stroke volume optimisation, indeed SVV achieved only 0.5 on the receiver-operator curve equivalent to tossing a coin.
11. Brandstrup B, Tonnesen H, Beier-Holgersen R et al, Effects of intravenous fluid restriction on post-operative complications: comparison of two perioperative fluid regimens a randomised assessor-blinded multicenter trial. Ann Surg 2003;238:641-8.
This classic paper highlighted the importance of avoiding salt and water overload in major surgery patients.
12. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients. GIFTASUP Jeremy Powell-Tuck (chair), Peter Gosling, Dileep N Lobo, Simon P Allison, Gordon L Carlson,Marcus Gore, Andrew J Lewington, Rupert M Pearse, Monty G Mythen www.asgbi.org.uk/en/surgical_resources_and_documents/
This is the most recent and comprehensive evidence based review of perioperative fluid management. It represents a consensus view of over 60 experts in anaesthesia, intensive care, surgery, renal medicine and chemical pathology.
Conflicts of Interest Dr Wakeling has received honoraria for lecturing and travel expenses to attend meetings from Deltex Medical
Enhanced Recovery Partnership Programme
Analgesia for open and laparoscopic surgery

Dr William Fawcett
FRCA FFPMRCA
Cancer Action Team
Consultant in Anaesthesia and Intensive Care Medicine

Royal Surrey County Hospital, Guildford, Surrey, UK
22/4/2010
http://www.18weeks.nhs.uk/
Colorectal Surgery Model Analgesia for open surgery
Open Surgery
Thoracic epidural anaesthesia classic approach y Well studied over last 20 years Many published benefits
Henrik Kehlet, MD, PhD
Surgeon and Professor of Perioperative Therapy at the Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Denmark.
Part of multimodal approach to postoperative recovery
Benefits of neuroaxial block

Overall reduction in: Mortality by 30% p y Deep vein thrombosis by 44% Pulmonary embolism by 55% Transfusion requirements by 50% Pneumonia by 39% Respiratory depression by 59%
(P < 0.001)
Epidurals and colorectal surgery

Reduction in reduce the classic pituitary, adrenocortical, and sympathetic responses to surgery g y Does not modify inflammatory or immunological responses Opioid sparing, quicker return to GI function
Also reductions in myocardial infarction and renal failure

Rodgers A et al. BMJ 2000;321:1493
Balanced or Multimodal analgesia

Kehlet H et al Anesthesia and Analgesia 1993;77:1048-56
Problems with analgesia

NSAIDs: renal, bleeding, perforation, anastomotic leakage Paracetamol Opioids: sedation, constipation, PONV Local anaesthetics
Variety of approaches to reduce opioid consumption including: Local anaesthetics including wound infusions Paracetamol NSAIDs Others including gabapentin, clonidine and ketamine, lignocaine
Epidurals
Well described problems include:
How good are epidurals?
Hypotension Poor mobility Neurological damage Up to 50% dont work adequately
MASTER trial
Rigg JRA et al. Lancet 2002;359:1276-82
Epidural analgesia: first do no harm

Low J et al Anaesthesia 2008;63:1-3
MASTER TRIAL
No overall difference in morbidity or mortality, even trend towards increasing mortality 5.1% vs 4.3% g y Less respiratory failure with epidurals 23.3% vs 30.2% (p=0.02)
Rigg JRA et al. Lancet 2002;359:1276-82
Epidurals and CVS

Hypotension and its effects on
Splanchnic and anastomotic perfusion Other organs eg heart, brain, kidneys
Treatment of hypotension
Fluids Vasopressors Pressure more important than flow
Gould TH. BJA 2002:89;446-51
Analgesia in open surgery summary

Multimodal analgesia
Paracetamol, NSAIDs, local anaesthetics Opiate sparing Epidurals: level 1-2 care for optimum treatment
Analgesia for laparoscopic surgery apa os op su g y
Pain teams Excellent pain control reduction in morbidity, mortality and hospital stay
Laparoscopic surgery
How much is transferable from open surgery? Little data for optimum analgesic technique in laparoscopic colorectal surgery
Laparoscopic vs open
Differences
Intraoperative cardiopulmonary stresses are greater and effects of block magnified g g Positioning can effect blocks Abdominal incision is smaller, transverse and below the umbilicus Shoulder tip pain Analgesic requirements at 24 hours can usually be addressed with oral analgesics
Simple analgesics often all that is required at 24 hours:
Paracetamol NSAIDs Tramadol/codeine
Laparoscopic surgery first 24 hours

Treatment options: Epidural Spinal iv morphine (PCA)
Intense analgesia for first 12-24 hours only
Analgesic regime
Epidural
Classic approach to enhanced recovery Avoidance of opioids p Parasympathetic tone ? Relevance of DVT/PE, blood loss, stress response, respiratory function
Analgesic regime
Spinal
Avoidance of systemic opioids Parasympathetic tone Mobilisation improved by single shot Higher success rate and lower complication compared to epidurals
BUT:
Risk of exaggerated CVS changes during positioning Risk of high block ?Poor mobilisation
BUT
Risk of exaggerated cardiovascular changes Risk of high block
Analgesic regime
Patient Controlled Analgesia Few cardiovascular changes Mobilisation not usually a problem BUT Opioids not recommended for enhanced recovery: ileus and PONV
Evidence in laparoscopic surgery

Epidurals
..thoracic epidural analgesia superior to PCA in accelerating the return of bowel g function and dietary intake, while providing better pain relief.
Taqi A et al. Surgical Endoscopy 2007;21:247-52
Thoracic epidurals improved early analgesia.

Senagore AJ et al. BJS. 2003;90:1195-9

Epidurals (contd)
.. better postoperative pain relief and relief, faster recovery of gastrointestinal function
Zingg U et al. Surgical Endoscopy 2009;23:276-282

Spinals
Very little evidence We used spinals successfully for first 2323 hourstay laparoscopic colectomy paper.
Levy BF. Scott MJP. Fawcett WJ. Rockall TA. Diseases of the Colon & Rectum. 2009;52:1239-43
No study has shown reduction in hospital stay
Currently patients undergoing RCT for epidural vs spinal vs PCA
Safe spinal anaesthesia

Isobaric bupivacaine produces unpredictable block Heavy bupivacaine needs 20 minutes to fix before pneumoperitoneum / head down 2 5mls 0.5%, diamorphine 2.5mg 2.5mls 0 5% 2 5mg Block height in recovery average T6 Sitting, awake GA + lines Mean time 20-25 minutes before start of surgery
Spinals emerging data

Well tolerated Need for vasoconstrictors less than epidurals Better preservation of respiratory function Good opioid sparing effects Reduced length of stay
Levy B et al BJS 2008; 95(S3):57 Levy B, Fawcett WJ, Scott MJP et al Anaesthesia 2009;64:810 Levy BF, Fawcett WJ, Scott MJP et al BJS 2009;96(S4):2-3
Frequency of vasoconstrictor use

Percentage of patients
Respiratory changes
Spinal
Preop Postop
Epidural
Preop Postop Preop
PCA
Postop
Spinal Epidural PCA
48% 89% 35% FEV1 (l) FVC (l) PEFR (l/min) 2.14 2.70 344 1.65 2.01 245 2.15 3.03 352 1.55 1.90 225 2.41 2.95 419 1.68 1.94 246
PCA vs epidural p=0.014 Spinal vs epidural p=0.049
Respiratory changes
Significant fall preop vs post op (p < 0.01) for all groups. There was better preservation of pulmonary function in spinal group compared to the other 2 groups (especially PCA) Significant fall in PEFR for spinal vs PCA (p=0.042)
Morphine consumption
Amount of morphine (mgs) for spinal patients Amount of morphine (mgs) for PCA patients
Mean Std deviation Range
6.0 10.2 45
59.9 33.1 146
Length of stay
Spinal Length of stay (days) 4.5* Epidural 7.2 PCA 4.2
What is the future?

Analgesia is a major component in ERPs Good analgesia alone is not the endpoint Multimodal analgesia vital Regular review by pain team and other staff A number of controversial areas still exist
* p=0.007 p<0.001
Lidocaine infusions Newer Areas

Reduction in analgesic requirements, ileus and PONV Opioid consumption reduced by 2/3 Reduced hospital stay BUT May be less relevant in small incision vs classical open surgery
Marrett E et al BJS 2008;95:1331-1338
Ketamine
When used intraoperatively and via infusion for 48 hours post op (2 mcg/kg/min after a 0.5 mg/kg bolus): Morphine consumption halved Side effects: sedation, delusions, nightmares, psychiatric disorders not manifest at these doses.
Zakine J et al. Anesth Analg 2008;106:185661
TAP blocks
Transversus abdominus plane block Many use ultrasound guidance Convincing opioid sparing effect for both open surgery (75%) and laparoscopic surgery (50%) Very promising
McDonnell JG et al. Anesth Analg 2007;104:193-197 El -Dawlatly AA et al. BJA 2009;102:763-7
BUT Dose and duration debated
Local Anaesthetic into Wound

Continuous infusion via elastomeric device Used in many types of surgery Promising early reduction in opioid consumption in open bowel surgery Little evidence so far in laparoscopic surgery
Polglase AL et al. Diseases of the Colon & Rectum. 2007;50:2158-2167
Contentious areas:
Stress response Analgesia is all that matters
Stress response
Systemic change following surgery and trauma:
Endocrine (pituitary and adrenals) Metabolic (catabolism, hyperglycaemia) Inflammatory (cytokines) Immunosuppression
Stress response
Neuroaxial blocks effective at reducing endocrine & metabolic changes especially for pelvic surgery Some claim this is key factor for ERP However this requires block with LA prior to LA, surgery and continued postoperatively This is not offered within ERPs - spinals>epidurals Starting/finish of block quickly reverses stress response modifications
Kehlet H. Acta Chir Scand Suppl. 1989;550:22-8 Fawcett WJ et al. Anaesthesia 1997;52:294-299
Magnified by starvation, infection and hypovolaemia Disappointingly, modification unproven benefit
Analgesia is all that matters

Anaesthetists rightly champion this aspect of care However excellent analgesia not the only consideration postoperatively Side effects from analgesia may compromise other aspects of ERP
Enhanced Recovery
Enhanced Recovery Fluid Therapy Analgesia
Early Mobility
Gut Function
Enhanced Recovery
Early Mobility Gut Function Modulation of stress response
Pitfalls in analgesia - epidurals

Fluid control
Even with GDFT may result in fluid overload
Mobilisation
Reduced Complications Healing Reduced Length of Stay
Early removal of catheters
Pitfalls in analgesia - PCA

Nausea and vomiting Ileus Early removal of catheters May require NG tubes
Perspective
Despite improved analgesia and a decrease in ileus, epidural analgesia has some adverse effects and does not shorten the duration of hospital stay after colorectal surgery.
Marret E et al. BJS 2007; 94: 665673
The anaesthetist has an important role in facilitating early postoperative recovery by provision of minimally-invasive anaesthesia and pain relief, and by collaborating with surgeons, surgical nurses, and physiotherapists to reduce risk and pain.
Kehlet H, Dahl JB. Lancet 2003; 362: 192128
Perspective
It is time to "roll up our sleeves and get back to work" doing high-quality clinical research rather than simply reanalyzing previously published studies bli h d t di
White PF, Kehlet H. Anesth Analg 2007;104:487-489
The future?
Use of local blocks eg wound inflitration/?TAP blocks in conjunction with other aspects of multimodal anaesthesia Epidurals may prove to be unnecessary within ERPs ? Role of spinals
The anaesthesiologist, as a key perioperative physician, is of critical importance to the surgical care team in fast track surgery
White PF, Kehlet H et al Anesth Analg 2007;104:1380-1396
Summary
We can no longer practice analgesia in isolation y q Constantly re-evaluate our technique Extrapolation of previous work maybe flawed Further research required
4/22/2010
Focus on laparoscopic colorectal procedures: Improving the periperioperative care pathway

Dr. Patrick Morgan 22nd April 2010
Introduction
PrePre-assessment Risk stratification PrePre-operative management Individualised approach PostPost-operative course
MultiMulti-disciplinary approach
Surgeon PrePre-assessment team Colorectal nurses Physiotherapists Occupational therapists Anaesthetists Pain management team Nutritional team Ward nursing staff Medical staff Social workers
Evidence based
Preoperative Intraoperative Postoperative mation for patients and procedure spec ning/reorganisation reduction Effective pain relie Stress Prehabilitation Prophylactic prophylaxis for nause antibiotics ohol and smoking oxygen therapy vomiting Perioperative cessationRegional anaesthesia mobilisatio ti Early utritionalMinimally invasive operationsfeeding Early oral support dietary Normothermia supplement eoperative fluid & Choice of incision bohydrate intake Intraoperative fluids Nursing care Less use of L f DL i d f T b d
PrePre-operative
Information for patients Prehabilitation Alcohol and smoking cessation Nutritional support (for malnourished patients) Preoperative fluid & carbohydrate intake Nursing care Less use of Mechanical bowel preparation
4/22/2010
Information
Education for patient and relatives Encourages motivation PrePre-hospital stoma education
PrePre-operative stoma education

42 patients Reduced hospital LOS Reduced time to stoma proficiency Reduced community stoma interventions Cost saving of 1119 per patient
Preoperative Intensive, Community-Based vs. Traditional Stoma CommunityEducation: A Randomized, Controlled Trial. Chaudhri et al. Dis Col Rect 2005
Prehabilitation
Reduced LOS in spinal surgical patients.
Costs and quality of life for prehabilitation and early rehabilitation after surgery of the lumbar spine Nielson et al. BMC Health Serv Res 2008
Risk Stratification
Improved cardiovascular exercise parameters.

Responsive Measures to Prehabilitation in Patients Undergoing Bowel Resection Surgery. Kim et al TJEM 2009
May be beneficial in certain subgroups
Population
Aging population with inherent co-morbidity coHigh risk patients requiring complex surgery, 12.5% of procedures, account for 83.8% of deaths 10.1% mortality in elective procedures admitted 10 1% to ITU immediately post-operatively post39% mortality in elective procedures admitted to ward and then ITU post-operatively postIdentification and characterisation of the high-risk surgical highpopulation in the United Kingdom. Pearse et al Crit Care 2006
Minimal surgical stress Maximal cardiovascular stress Consideration for exclusion criteria
4/22/2010
What goes wrong

Increased oxygen demand peri-operatively periCardio respiratory reserve Failure to increase oxygen delivery Misdiagnosis of the problem Misunderstanding of th problem Mi d t di f the bl Missing the problem
PrePre-operative assessment
Need to assess cardiovascular function Static and dynamic parameters Stratification of risk
Cardiopulmonary exercise testing

Age > 60 Age<60 with CVS disease
AT<11 ITU 153 pts. 4.6% mortality
AT>11 + ischaemia HDU 115 pts 1.7% mortality
AT >11 Ward 280 patients 0% mortality
Relationship between the inability to climb two flights of stairs and outcome after major non-cardiac surgery: implications for the nonprepre-operative assessment of functional capacity. Biccard et al. Anaesthesia 2005
Cardiopulmonary exercise testing as a screening tool for perioperative management of major surgery in the elderly. Older et al Chest 1999
Questionnaire, Shuttle walk test, CPX Poor discrimination of risk High proportion of equivocal results CPX objective measurement of fitness
Assessing fitness for surgery: a comparison of questionnaire, incremental shuttle walk and cardiopulmonary exercise testing in general surgical patients. Struthers et al. BJA 2008
Immediately pre-operatively preHydration
CPX anaerobic threshold and peak O2 consumption
4/22/2010
Maximising patients hydration pre operatively

1.Essential 2.Quite Important 3.Indifferent 4.Not Important 5.Potentially harmful 64% 34% 1% 0% 0%
Insulin resistance after surgery

Worsened by fasting Reduced by regional anaesthetic Reduced by less surgical stress Prolonged duration post-operatively postAssociated with length of stay
Insulin resistance
Independent predictive factors on length of stay

Type of surgery Blood loss Insulin resistance postoperatively
Insulin resistance is proportional to magnitude of surgery

Insulin resistance-a marker of surgical stress. Thorell et al Curr Opin Clin Nutr resistanceMetab Care 1999
Carbohydrate loading
Reduces metabolic stress Reduces insulin resistance Patient satisfaction improved Earlier bowel function normality Reduces length of stay
Carbohydrate loading
100 g night before surgery 50 g morning of surgery Free fluid to 2 hrs pre-operatively preNo evidence of aspiration risk
4/22/2010
Less use of M h i lb
Preoperative Postoperative Stress and procedure spec ning/reorganisation reduction pain relie Effective rmation for patients Prophylactic prophylaxis for nause antibiotics Prehabilitation cohol Perioperative oxygen therapy and smoking vomiting R i Regional anaesthesiamobilisatio l cessation th i Early Minimally operations utritional support invasive Early oral feeding reoperative fluidNormothermia supplement dietary & rbohydrate intake Choice of incision Nursing care Intraoperative fluids l L f T b d
IntraIntra-operative Intraoperative
IntraIntra-operative
Individualised fluid management Flow monitoring Oesophageal Doppler Alternative measures of flow Analgesia
Avoiding crystalloid overload

Essential Quite Important Indifferent Not Important Potentially harmful 72% 25% 3% 0% 0% Very easy 25% Easy 14% Not easy 47% Extremely difficult 14%
Individualised approach
Individualised goal directed fluid therapy

Essential 58% Quite Important 36% Indifferent 6% Not Important 0% Potentially harmful 0% Very easy Easy Not easy Very difficult 15% 41% 33% 10%
Minimally invasive cardiac output
4/22/2010
Vigileo/Flotrac
Pulse pressure algorithm from arterial waveform Mathematical interpretation of waveform with anthropometric data Repeatedly revised algorithm No N external calibration t l lib ti Second algorithm relatively inaccurate
Vigileo/Flotrac
Most recent algorithm Compared with PAFC, TTE SVV 10% and PPV 12% highly predictive of fluid responsiveness CVP and PAOP non-predictive d nondi ti
Uncalibrated pulse contour-derived stroke volume variation contourpredicts fluid responsiveness in mechanically ventilated patients undergoing liver transplantation. Biais et al BJA 2008
Vigileo/Flotrac
TOE vs pulse contour analysis Measurements at lithotomy, pneumoperitoneum and falls in pressure below baseline Percentage error of 40% between modalities
Vigileo/Flotrac
Pulse Contour analysis vs. ODM IntraIntra-abdominal surgery Poor predictor of fluid responsiveness
Lahner et al. Evaluation of stroke volume variation obtained by arterial pulse contour analysis to predict fluid responsiveness intraoperatively. BJA 2009
Concha et al. Pulse contour analysis and transesophageal echocardiography: a comparison of measurements of cardiac output during laparoscopic colon surgery. Anesth Analg 2009
LiDCOrapid LiDCOrapid
Designed for use in operating theatre PulseCo arterial algorithm Validated over variety of clinical situations Provides a nominal stroke volume Accurate trending of stroke volume Predictive of fluid responsiveness using SVV and PPV
Pulse pressure variation

33 elective high-risk intra-abdominal surgical highintrapatients Intervention arm received HAES 6% boluses to minimise and maintain PPV <10% intraintraoperatively At PPV<10%, further fluid boluses are unlikely to improve SV Intervention group received more fluid, had less complications(1.4 vs. 3.9, p<0.05) and reduced hospital stay(7 vs. 17 days, p<0.01)
Lopes et al. Goal-directed fluid management based on pulse Goalpressure variation during high risk surgery: a pilot randomised controlled trial. Crit Care 2007
4/22/2010
Thoracic bioimpedence
Nasogastric tube
Prophylactic decompression Slows return of bowel function, p<0.00001. Trend to increased pulmonary complications, vomiting and patient discomfort.
Nelson et al. Nasogastric decompression used routinely after abdominal surgery does not speed recovery . Cochrane Datrabase of systematic reviews 2007
Effective pain relie ning/reorganisation reduction and procedure spec rmation for patients Stress prophylaxis for naus Prehabilitation Prophylactic antibiotics vomiting cohol and smoking Perioperative oxygen therapy E l Early bili t cessation Regional anaesthesia mobilisat operations utritional Minimally invasiveEarly oral feeding support reoperative fluid Normothermia supplemen & dietary
rbohydrate intake Choice of incision Nursing care Intraoperative fluids Less use of M h i lb L l fD i d
Preoperative Intraoperative
PostPost-operative Postoperativ
PostPost-operative optimisation
162 general surgical patients Conventional vs. goal directed therapy 8 hours post operatively Intervention group colloid +/- dopexamine to +/achieve target DO2I of 600 ml/min/m2 Control arm colloid to achieve sustained rise of C t l ll id t hi t i d i f 2 mmHg in CVP Less complications(44% vs. 68%, p=0.003) and reduced hospital stay (11 vs. 14 days, p=0.001)
Early goal-directed therapy after major surgery reduces goalcomplications and duration of hospital stay. Pearse et al. Crit Care 2005
PostPost-operative
Effective pain relief Nausea and vomiting limitation Early mobilisation 2 hours day 1 Day 2 - 6 hours mobilisation Early oral feeding and dietary supplementation Less use of Tubes, drains and catheters
Early nutritional support

Encourage oral fluid in recovery Immediate nutrition with epidural analgesia Improved mobility (5.5 vs. 1.7 hrs/day) Improved protein and calorific intake
Early oral nutrition after elective colorectal surgery: influence of balanced analgesia and enforced mobilisation. Henriksen et al. Nutrition 2002
4/22/2010
Less tubes, drains and catheters

Epidural catheters Central venous catheters Central venous pressure monitoring Central venous saturation monitoring
ScvO2
PeriPeri-operative factors Hypoxia Shivering Anaemia Myocardial ischaemia Correlates well with SvO2 Poor correlation with DO2
Comparison of central venous oxygen saturation and mixed venous oxygen saturation during liver transplantation. El Masry et al. Anaesthesia 2009
ScvO2
8 hours Post-operative ScvO2 PostTarget for complications 64.4% Fall immediately post-op postSignificant fluctuation in ScvO2 Fluctuations not related to DO2 No change in C.I.
Changes in central venous saturation after major surgery, and association with outcome. Pearse et al. Critical Care 2005, 9:R6949:R694-96
PeriPeri-operative fluid requirement

Fluid Requirement
5 Time
10
PeriPeri-operative fluid monitoring

How long to monitor the patient? Do we need ScvO2? Do we need a Central Venous Catheter? Individualised, monitored approach or... All patients to receive fluid bolus at 8 hours?
PostPost-operative care
Dedicated area may improve results Staff related Organisational
4/22/2010
PostPost-operative course
3 patient groups 1. Meet discharge criteria 2. Delay to discharge criteria 3. Criteria met but discharge delayed
Is a protocol enough?
5 centre study 425 patients Low compliance with protocol post-operatively postGoal of readiness for discharge on day 3 High number of patients discharged on day 5 Need repeated team meetings/ discussions etc
A protocol is not enough to implement an enhanced recovery programme for colorectal resection Maessen et al. BJS 2007
Policy change
Historical matched study Delay in discharge from pre-set criteria preImproved since introduction of ERAS programme Main reason for delay- wound care delayReduction in length of stay related to changes in local staff policy
Additional factors
Audit and ongoing assessment Documentation Hospital stay Morbidity Safety Cost Patient satisfaction Patient follow up
ERAS group. Length of Stay: An Inappropriate Readout of the Success of Enhanced Recovery Programs. World J Surg 2008
Patient Safety
Robust protocolised approach Safety net for discharges Improving quality Improving education Audit
Patient safety
MetaMeta-analysis 1021 patients Reduced length of stay Reduced morbidity No difference in readmission rates No difference in mortality
FastFast-track vs standard care in colorectal surgery: a meta-analysis metaupdate. Gouvas et al. Int J Col Dis 2009.
4/22/2010
Patient outcome
183 historical matched patients ERAS vs conventional morbidity 14.8% vs 33.6%, p<0.01 Hospital stay 6 vs. 9 days, p=0.03 No difference in mortality N diff i t lit No difference in readmission rates
Enhanced recovery after surgery versus conventional postoperative care in colorectal surgery. Teeuwen et al. J Gastrointest Surg 2009
Conclusion
MultiMulti-disciplinary approach Education Patient selection and stratification Individualised management Protocolised management
10
REVIEW ARTICLE
Consensus Review of Optimal Perioperative Care in Colorectal Surgery

Enhanced Recovery After Surgery (ERAS) Group Recommendations
Kristoffer Lassen, MD, PhD; Mattias Soop, MD, PhD; Jonas Nygren, MD, PhD; P. Boris W. Cox, MD; Paul O. Hendry, MBChB, MRCS; Claudia Spies, MD, PhD; Maarten F. von Meyenfeldt, MD, PhD; Kenneth C. H. Fearon, MD, FRCS; Arthur Revhaug, MD, PhD; Stig Norderval, MD, PhD; Olle Ljungqvist, MD, PhD; Dileep N. Lobo, DM, FRCS; Cornelis H. C. Dejong, MD, PhD; for the Enhanced Recovery After Surgery (ERAS) Group
Objectives: To describe a consensus review of opti-
Data Extraction: A consensus recommendation for each
mal perioperative care in colorectal surgery and to provide consensus recommendations for each item of an evidence-based protocol for optimal perioperative care.
Data Sources: For every item of the perioperative treat-
protocol item was reached after critical appraisal of the literature by the group.
Data Synthesis: For most protocol items, recommendations are based on good-quality trials or metaanalyses of such trials. Conclusions: The Enhanced Recovery After Surgery (ERAS) Group presents a comprehensive evidence-based consensus review of perioperative care for colorectal surgery. It is based on the evidence available for each element of the multimodal perioperative care pathway.
ment pathway, available English-language literature has been examined.

Study Selection: Particular attention was paid to meta-
analyses, randomized controlled trials, and systematic reviews.
Arch Surg. 2009;144(10):961-969

meta-analysis of RCTs with homogeneity were designated as grade A. Other recommendations were designated as consensus recommendations based on the best available evidence. The evidence is presented in the text and the recommendations are summarized in the Table. RESULTS
AST-TRACK OR ENHANCEDrecovery programs integrate a range of perioperative interventions proven to maintain physiological function and facilitate postoperative recovery, especially after elective colonic resections in dedicated centers.1-4 TheEnhancedRecoveryAfterSurgery (ERAS) Group has achieved similar results in general surgical departments using an evidence-based care platform.5,6 We present an updated and expanded consensus review of perioperative care for colorectal surgery based on the evidence available for each element of the multimodal pathway.
PREADMISSION INFORMATION AND COUNSELING Explicit preoperative information can facilitate postoperative recovery and pain control, particularly in patients exhibiting denial and anxiety.8,9 Aclearexplanationofexpectations during hospitalization facilitates adherence to the care pathway and allows early recovery and discharge.10,11 At this first encounter, the patient should also be given a clear role with specific tasks, including targets for postoperative food intake, oral nutritional supplements, and mobilization.12,13 PREOPERATIVE BOWEL PREPARATION Mechanical bowel preparation can cause dehydration and fluid and electrolyte abnor-
METHODS The MEDLINE database was searched up to December 31, 2007 (3 exceptions were made: 2 meta-analyses and an editorial published in 2008), and the ERAS protocol6 from 2005 was updated. Recommendations were evaluated according to the system developed by the Centre for Evidence Based Medicine, Oxford, England.7 Those based on at least 2 good-quality randomized controlled trials (RCTs) (in patients undergoing gastrointestinal surgery) or 1
Author Affiliations are listed at the end of this article. Group Information: The Enhanced Recovery After Surgery (ERAS) Group members are listed at the end of this article.
(REPRINTED) ARCH SURG/ VOL 144 (NO. 10), OCT 2009 961
WWW.ARCHSURG.COM
Downloaded from www.archsurg.com at University of Nottingham, on October 19, 2009 2009 American Medical Association. All rights reserved.
Table. Consensus Guidelines

Item Preadmission information and counseling Preoperative bowel preparation Guideline Patients should receive oral and written preadmission information describing what will happen during hospitalization, what they should expect, and what their role is in the recovery process. Patients undergoing elective colonic resection above the peritoneal reflection should not receive routine oral bowel preparation (grade A). Bowel preparation may be considered in patients scheduled for low rectal resection where a diverting stoma is planned. The duration of preoperative fasting should be 2 hours for liquids and 6 hours for solids (grade A). Patients should receive carbohydrate loading preoperatively (grade A). Patients should not receive medications known to cause long-term sedation, from midnight prior to surgery. Short-acting medications given to facilitate insertion of epidural catheter are acceptable (grade A). The preferred methods for prophylaxis in patients undergoing elective colorectal surgery are subcutaneous low-dose unfractionated heparin or subcutaneous low-molecular-weight heparin (grade A). Patients undergoing colorectal resection should receive single-dose antibiotic prophylaxis against both anaerobes and aerobes about 1 hour before surgery (grade A). Long-acting opioids should be avoided in patients undergoing anesthesia. Patients should receive a midthoracic epidural commenced preoperatively and containing local anesthetic in combination with a low-dose opioid (grade A). Prevention of postoperative nausea and vomiting should be induced if 2 risk factors are present. Treatment should be immediate, with combinations of the drugs discussed. Laparoscopic colonic resection is recommended if the surgeon or department is proficient with the technique and prospectively validated outcomes show at least equivalence to open surgery (grade A). A midline or transverse laparotomy incision of minimal length should be used for patients undergoing elective colorectal resection. Nasogastric tubes should not be used routinely in the postoperative period (grade A). They should be inserted if ileus develops. Intraoperative maintenance of normothermia with an upper-body forced-air heating cover should be used routinely (grade A). Intraoperative and postoperative fluid restriction in major colonic surgery with avoidance of hypovolemia is safe (grade A). When compared with excessive fluid regimens, normovolemic regimens in major colonic surgery lead to more favorable outcomes (grade A). Intraoperative goal-directed therapy (eg, with transesophageal Doppler monitoring) is superior to a non-protocol-based standard with respect to outcome (grade A) and should be considered on an individual basis. Drains are not indicated following routine colonic resection above the peritoneal reflection (grade A). Short-term ( 24-hour) use of drains after low anterior resections may be advisable. Suprapubic urinary drainage for pelvic surgery is recommended (grade A). For colonic surgery, both suprapubic and urethral techniques are appropriate. Midthoracic epidural analgesia and avoidance of fluid overload are recommended to prevent postoperative ileus (grade A). A laparoscopic approach is recommended if locally validated (grade A). A low-dose postoperative laxative such as magnesium oxide may also be considered. Patients should receive continuous epidural midthoracic low-dose local anesthetic and opioid combinations (grade A) for approximately 48 hours following elective colonic surgery and approximately 96 hours following pelvic surgery. Acetaminophen (paracetamol) should be used as a baseline analgesic (4 g/d) throughout the postoperative course. For breakthrough pain, epidural boluses should be given while the epidural is running. Nonsteroidal anti-inflammatory drugs should be started at removal of the epidural. Patients should be encouraged to commence an oral diet at will after surgery (grade A). Oral nutritional supplements should be prescribed (approximately 200 mL, energy dense, 2-3 times daily) from the day of surgery until normal food intake is achieved. Continuation of oral nutritional supplements at home for several weeks is recommended for nutritionally depleted patients (grade A). Patients should be nursed in an environment that encourages independence and mobilization. A care plan that facilitates patients being out of bed for 2 hours on the day of surgery and 6 hours thereafter is recommended. A systematic audit should be performed to allow direct comparison with other institutions.
Preoperative fasting and preoperative carbohydrate loading Preanesthetic medication
Prophylaxis against thromboembolism
Antimicrobial prophylaxis Standard anesthetic protocol
Preventing and treating postoperative nausea and vomiting Laparoscopy-assisted surgery Surgical incisions Nasogastric intubation Preventing intraoperative hypothermia Perioperative fluid management
Drainage of peritoneal cavity following colonic anastomosis Urinary drainage Prevention of postoperative ileus
Postoperative analgesia
Postoperative nutritional care
Early mobilization
Audit
malities, particularly in elderly patients.14 Two recent large, multicenter RCTs15,16 confirm the conclusions of earlier meta-analyses17-19 that bowel preparation is not beneficial in elective colonic surgery, and 2 smaller recent RCTs suggest that it increases the risk for anastomotic leak.20,21 Bucher et al20 included only left-sided colonic resections and demonstrated increased morbidity after routine bowel cleansing. Bowel preparation may be necessary in selected patients who require intraoperative colonoscopy. For colonic surgery, data indicate that bowel preparation is stressful and prolongs postoperative ileus.22
A 2005 Cochrane analysis23 included 231 low anterior resections without finding an increased leak rate in those without bowel preparation. A recent RCT that included a substantial proportion of ultralow rectal anastomoses24 reported that bowel preparation protects against anastomotic leaks requiring reoperations. There was, however, increased cardiovascular mortality in the group receiving bowel preparation. Further trials are needed to establish the optimal routine for very low rectal resections. Nevertheless, logic dictates that the bowel distal to the stoma should be cleansed if
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a diverting stoma is constructed to protect the anastomosis. PREOPERATIVE FASTING AND PREOPERATIVE CARBOHYDRATE LOADING Although fasting from midnight has been standard practice to avoid pulmonary aspiration in elective surgery, a review has found no evidence to support this.25 Equally, a Cochrane review26 of 22 RCTs in adult patients provides robust evidence that reducing the preoperative fasting period for clear fluids to 2 hours does not increase complications. National Anaesthesia Societies now recommend intake of clear fluids until 2 hours before induction of anesthesia as well as a 6-hour fast for solid food.27-30 Obese and even morbidly obese patients have the same gastric emptying characteristics as lean patients.31,32 Diabetic patients with neuropathy may have delayed gastric emptying, possibly increasing the risk of regurgitation and aspiration.33 Patients with uncomplicated type 2 diabetes mellitus can have normal gastric emptying, and a study of preoperative carbohydrate loading did not find increased aspiration rates in such patients.34 Having patients undergo surgery in a metabolically fed state can be achieved by provision of a clear carbohydraterich beverage before midnight and 2 to 3 hours before surgery. This reduces preoperative thirst, hunger, and anxiety26,35 and postoperative insulin resistance.36 Patients in a more anabolic state have less postoperative nitrogen and protein losses37,38 as well as better-maintained lean body mass39 and muscle strength.40 Data from RCTs indicate accelerated recovery and shorter hospital stay in patients receiving preoperative carbohydrate loading in colorectal surgery.41,42 PREANESTHETIC MEDICATION Adverse effects from long-acting premedication such as opioids, long-acting sedatives, and hypnotics hamper recovery (eg, immediate ability to drink and mobilization after surgery), leading to prolonged length of stay.43 Shortacting anxiolytics do not prolong recovery or length of stay.44 PROPHYLAXIS AGAINST THROMBOEMBOLISM Meta-analyses have shown subcutaneous low-dose unfractionated heparin regimens to be effective in reducing deep vein thrombosis, pulmonary embolism, and mortality in patients undergoing colorectal surgery.45-48 Metaanalyses comparing low-molecular-weight heparin (LMWH) with unfractionated heparin have shown no difference in efficacy47,48 or associated bleeding risks.49,50 The LMWH is preferable because of its once-daily dosage and a lower risk of heparin-induced thrombocytopenia.50-52 Although antiplatelet drugs and intravenous dextran are less effective for prophylaxis of deep vein thrombosis and in reducing mortality, they can be as effective for the prevention of pulmonary embolism.48,53 Their adverse effect profiles53,54 make them advisable only in highrisk patients when LMWH and unfractionated heparin are contraindicated.
The safety of continuing LMWH and continuous epidural analgesia is debatable. In the United States, higher doses of LMWH are used twice daily and may account for the greater numbers of epidural hematomas reported.55 Prophylactic doses of LMWH should be given no later than 12 hours prior to insertion and removal of an epidural catheter.56,57 Although concomitant use of nonsteroidal anti-inflammatory drugs and LMWH is considered safe, a potential link with epidural hematoma is debated. Care should be taken with other factors affecting coagulation, and alternative thromboprophylaxis (such as thromboembolism-deterrent stockings) should be used when appropriate. ANTIMICROBIAL PROPHYLAXIS The use of prophylactic antibiotics effective against both aerobes and anaerobes can minimize infectious complications in colorectal surgery,58 with the first dose being administered about 1 hour prior to skin incision.59 A single dose is as effective as multidose regimens, but further doses should be given in prolonged cases ( 3 hours).58 The optimal combination of antibiotics is not established, but a second-generation cephalosporin and metronidazole are suggested. New generations of antibiotics should be reserved for infectious complications. STANDARD ANESTHETIC PROTOCOL There is no evidence to direct the choice of the optimal anesthetic method for colorectal procedures. However, it is rational to use short-acting agents (propofol, remifentanil hydrochloride)60 instead of long-acting intravenous opioids (morphine sulfate, morphine hydrochloride, fentanyl citrate), thereby allowing proactive recovery to start soon after surgery. Short-acting inhalational anesthesia is a reasonable alternative to total intravenous anesthesia. There is no evidence that intraoperative epidural analgesia improves postoperative outcome in colorectal procedures, but its use reduces the dose of general anesthetic agents. For colonic surgery, the epidural catheter is best placed at the midthoracic level (T7/8) to achieve both analgesia and sympathetic blockade, preventing gut paralysis.61 If activated before commencement of surgery, it blocks stress hormone release and attenuates postoperative insulin resistance.62 The catheter is inserted in the awake patient to avoid neurological complications. Intraoperatively, the block can be maintained by continuous infusion of local anesthetic (eg, bupivacaine hydrochloride, 0.1%0.25%, or ropivacaine hydrochloride, 0.2%) plus a lowdose opiate (eg, 2.0-g/mL fentanyl citrate or 0.5- to 1.0g/mL sufentanil citrate) at 4 to 10 mL/h. Epidural opioids in small doses act synergistically with epidural local anesthetics in providing analgesia,63 without major systemic effects.64-66 Addition of epinephrine (1.5- to 2.0-g/mL) to the thoracic epidural infusion improves analgesia.67-69 PREVENTING AND TREATING POSTOPERATIVE NAUSEA AND VOMITING Patient experience suggests that postoperative nausea and vomiting can be more stressful than pain.70-73 Risk facWWW.ARCHSURG.COM
tors include being female and having nonsmoking status, history of motion sickness (or postoperative nausea and vomiting), and postoperative administration of opioids.74,75 Individuals at moderate risk (2 factors) should receive prophylaxis with dexamethasone sodium phosphate at induction or serotonin receptor antagonist at the end of surgery.76 High-risk individuals (3 factors) should receive general anesthesia with propofol and remifentanil as well as 4 to 8 mg of dexamethasone sodium phosphate at the beginning of surgery, supplemented with serotonin receptor antagonists or droperidol76 or with 25 to 50 mg of metoclopramide hydrochloride 30 to 60 minutes before the end of surgery.77 LAPAROSCOPY-ASSISTED SURGERY The most recent meta-analysis78 confirms that significant improvements in short-term outcomes are achievable by laparoscopy-assisted colonic resection as a single intervention. This was associated with significant reductions in short-term wound morbidity, time to first bowel movement, and discharge from the hospital. The potential of combining laparoscopy and enhancedrecovery care has been evaluated in only 2 small trials randomizing patients to either laparoscopy-assisted or open surgery within an established enhanced-recovery protocol.79,80 In the setting of a long-established and efficient enhanced-recovery protocol, no further improvement in short-term outcome was seen by adding laparoscopy (median postoperative length of stay of 2 days in both groups).79 The second study had longer hospitalizations, and here a reduction in postoperative stay was seen in the laparoscopy-assisted group as compared with the group undergoing open surgery (3.5 vs 6 days, respectively).80 Further investigation will hopefully more clearly evaluate the full potential of combining laparoscopy and enhanced-recovery care.81 SURGICAL INCISIONS Some RCTs suggest that transverse or curved incisions cause less pain and pulmonary dysfunction than vertical incisions following abdominal procedures,82,83 while others have found no advantage of transverse incisions.84,85 A recent Cochrane review86 of RCTs comparing midline with transverse incisions for abdominal surgery confirms that although analgesic use and pulmonary compromise may be reduced with transverse or oblique incisions, complication rates and recovery times are the same as with midline incisions. Hence, while incision length affects patient recovery,87 the choice of incision for abdominal surgery still remains the preference of the surgeon. NASOGASTRIC INTUBATION A meta-analysis88 in 1995 showed that routine nasogastric decompression should be avoided after colorectal surgery since fever, atelectasis, and pneumonia are reduced in patients without a nasogastric tube. A recent Cochrane meta-analysis89 of 33 trials with more than 5000 patients confirmed this and also found earlier return of
bowel function in patients when nasogastric decompression was avoided. Gastroesophageal reflux is increased during laparotomy if nasogastric tubes are inserted,90 and there is no rationale for routine insertion of a nasogastric tube during elective colorectal surgery, except to evacuate air that may have entered the stomach during ventilation by facial mask prior to endotracheal intubation. Nasogastric tubes placed during surgery should be removed before reversal of anesthesia. PREVENTING INTRAOPERATIVE HYPOTHERMIA Several RCTs have demonstrated that preservation of normothermia by using an upper-body forced-air heating cover reduces wound infections,91,92 cardiac complications,92-94 bleeding, and transfusion requirements.92,95 Extending systemic warming to 2 hours before and after surgery had additional benefits.96 PERIOPERATIVE FLUID MANAGEMENT It has been standard practice in recent years to infuse volumes of intravenous fluids substantially in excess of actual perioperative losses.97 Traditional perioperative intravenous fluid regimens in abdominal surgery can lead to patients receiving 3.5 to 7 L of fluid on the day of surgery and more than 3 L/d for the following 3 to 4 days, leading to a 3- to 6-kg weight gain.98,99 Such regimens can delay the return of normal gastrointestinal function,98 impair wound or anastomotic healing, and affect tissue oxygenation, leading to prolonged hospitalization.99,100 Several trials have compared restrictive and liberal fluid or sodium regimens.98-102 The results are not uniform and comparison is difficult as administered volumes and electrolytes in both arms differed substantially, reflecting nonuniform standard practice. However, evidence does suggest that avoidance of overload and restricting fluid intake to that which will maintain balance, guided by body weight, may significantly reduce postoperative complications and shorten hospital stay and should therefore be recommended.98,100 The best way to limit postoperative intravenous fluid administration is to stop intravenous infusions and return to oral fluids early, which should be feasible on the first postoperative day.1 Patients with epidural anesthesia experiencing hypotension due to vasodilation and relative intravascular hypovolemia, which is traditionally treated with fluid loading, can be treated with the judicious use of a vasopressor.103 Intraoperative transesophageal Doppler monitoring helps titrate fluids in relation to cardiac output and may be useful in high-risk patients. Four RCTs104-107 and a metaanalysis108 with patients undergoing major bowel surgery found that when intraoperative fluid administration was guided by transesophageal Doppler monitoring, there was a better ejection fraction, better oxygenation, and fewer postoperative complications. Although patients in these trials were not treated according to enhanced-recovery protocols, it seems that transesophageal Doppler monitoring enables optimization of intravascular volume and tissue perfusion in major abdominal surgery. In low-risk patients undergoing surWWW.ARCHSURG.COM
gery of moderate magnitude, flow-guided therapy may not be warranted. High-grade evidence regarding the optimal regimen in terms of timing, type of fluid, and risk stratification is currently lacking. DRAINAGE OF PERITONEAL CAVITY FOLLOWING COLONIC ANASTOMOSIS Meta-analyses109,110 have demonstrated that the use of drains after colonic surgery does not reduce the incidence or severity of anastomotic leaks or other complications. Drainage of the pelvic cavity for 24 hours following low anterior resection is supported by the Dutch total mesorectal excision trial,111 although this remains to be proven in RCTs specifically designed to answer this question. URINARY DRAINAGE A recent meta-analysis112 of RCTs concluded that suprapubic catheterization is more acceptable to patients and reduces morbidity compared with urethral catheterization. Most trials have been undertaken in patients requiring 4 to 7 days of urinary drainage. The risk of urinary retention after only 24 hours of catheterization is low after colonic resection above the peritoneal reflection during epidural analgesia.113 Therefore, the advantages of suprapubic over urethral catheterization are probably small for colonic surgery, while the benefits are significant for pelvic surgery with longer catheterization times. PREVENTION OF POSTOPERATIVE ILEUS Prevention of postoperative ileus, a major cause of delayed discharge after abdominal surgery, is a key objective of enhanced-recovery protocols. While no current prokinetic agent is effective in attenuating or treating postoperative ileus, several other interventions have been successful. Midthoracic epidural analgesia61 as compared with intravenous opioid analgesia is highly efficient at preventing postoperative ileus.65,114 Fluid overloading during101 and after98 surgery impairs gastrointestinal function and should be avoided. Oral magnesium oxide has been demonstrated to promote postoperative bowel function in a double-blinded RCT in abdominal hysterectomy115 and in reports from a well-established enhancedrecovery program in colonic resection.1,116 Laparoscopyassisted colonic resection also leads to faster return of bowel function as well as resumption of an oral diet compared with open surgery.78 Oral alvimopan, a -opioid receptor antagonist approved for clinical use in postoperative ileus, accelerates gastrointestinal recovery and reduces the duration of hospitalization in patients undergoing colonic resection compared with postoperative intravenous opioid analgesia.117 POSTOPERATIVE ANALGESIA Meta-analyses have shown that optimal analgesia is achieved by continuous epidural local anesthetic with or without opioids for 2 to 3 days postoperatively in both
open64,114 and laparoscopic118 surgery. Analgesia based on intravenous opioids does not provide the same efficient analgesia114 and has fewer beneficial effects on surgical stress responses compared with epidural local anesthetic techniques. While it is possible to achieve almost the same pain scores with patient-controlled analgesia at rest compared with epidural analgesia, this is at the expense of patients remaining sedated and in bed. Some RCTs114,119 have demonstrated that continuous epidural local anesthetic techniques reduce pulmonary morbidity but not other types of morbidity, hospital stay, or convalescence. There are some concerns about the risk of anastomotic complications after epidural analgesia for colonic resection.114,120,121 Perfusion of the splanchnic area after establishment of the epidural block is probably more closely associated with changes in mean arterial pressure than with changes in cardiac output.122 Therefore, vasopressors to maintain pressure should be considered. In the case of cardiac insufficiency, an adequate preload and positive inotropes are mandatory to improve colonic blood flow. Lowdose norepinephrine and dobutamine hydrochloride are probably not harmful for splanchnic perfusion.123-127 The unanswered questions are the acceptable range of blood pressure in individual patients and the duration for which vasopressors should be used.120 Avoidance of opioids and their adverse effects is the goal after removal of the epidural catheter, and nonsteroidal anti-inflammatory drugs have been shown to be opioid sparing128 and to provide efficient analgesia during this period.1,129 Nabumetone is a widely used nonsteroidal anti-inflammatory drug that does not affect bleeding time and may be a safer choice in patients with epidurals.130 POSTOPERATIVE NUTRITIONAL CARE The RCTs of early enteral or oral feeding vs nil by mouth conclude that there is no advantage of keeping patients fasted after elective gastrointestinal resection.131-133 Early feeding reduced both the risk of infection and the length of hospital stay and was not associated with an increased risk of anastomotic dehiscence. However, the risk of vomiting increased in patients fed early, and in the absence of multimodal anti-ileus therapy, early feeding was associated with bloating, impaired pulmonary function, and delayed mobilization.134,135 For malnourished patients, there is a clear advantage of prescribing postoperative oral nutritional supplements for 8 weeks in terms of recovery of nutritional status, protein economy, and quality of life.136 Positive clinical outcomes from oral nutrition supplements have also been documented in studies of patients undergoing elective surgery who are not screened for malnutrition.137,138 In enhanced-recovery programs, oral nutritional supplements have been used successfully on the day prior to operation and for at least the first 4 postoperative days to achieve recommended intakes of energy and protein.1,139,140 When used in combination, preoperative oral carbohydrate loading, epidural analgesia, and early enteral nutrition have been shown to result in nitrogen equilibrium without concomitant hyperglycemia.141
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EARLY MOBILIZATION Bed rest not only increases insulin resistance and muscle loss but also decreases muscle strength, pulmonary function, and tissue oxygenation.142 Additionally, there is an increased risk of thromboembolism. Effective pain relief using ambulatory thoracic epidural analgesia is a key adjuvant measure to encourage postoperative mobilization. A prescheduled care plan should list daily goals for mobilization, and a patient diary for out-of-bed activities is helpful. It is essential that the patient is nursed in an environment that encourages early mobilization (food and television removed from the bedroom) and one that maintains the patients independence (ordinary ward or level 1 facility). The aim is for patients to be out of bed for 2 hours on the day of surgery and for 6 hours per day until discharge. Abdominal drains and urinary catheters hinder mobilization and should be avoided whenever possible. AUDIT A systematic audit is mandatory to determine clinical outcome and to establish the successful implementation of the care protocol. Distinguishing between unsuccessful implementation and lack of desired effect from an implemented protocol is vital if results are short of desired quality standards. Comparison with other centers using similar protocols via identical tools of registration and identical definitions of key factors is needed.
COMMENT
This article outlines the recommendations of the ERAS Group for clinical perioperative care of patients undergoing elective colorectal surgery, based on the best available evidence. However, neither evidence nor protocol is sufficient to ensure evidence-based care. Evidence dictates care only to a very limited extent,143 and an evidencebased protocol alone is insufficient to ensure change.144 We echo the words of Urbach and Baxter: the immediate challenge to improving the quality of surgical care is not discovering new knowledge, but rather how to integrate what we already know into practice.145 Accepted for Publication: October 21, 2008. Author Affiliations: Department of Gastrointestinal Surgery, University Hospital Northern Norway and Institute of Clinical Medicine, University of Troms, Troms, Norway (Drs Lassen, Revhaug, and Norderval); Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, New Zealand (Dr Soop); Department of Surgery, Ersta Hospital (Dr Nygren), Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (Dr Nygren), and Division of Surgery, Karolinska Institutet, CLINTEC, Karolinska University Hospital Huddinge (Dr Ljungqvist), Stockholm, Sweden; Departments of Anaesthesiology and Pain Therapy (Dr Cox) and Surgery and NUTRIM (Drs von Meyenfeldt and Dejong), Maastricht University Medical Centre, Maastricht, the Netherlands; Department of
Clinical and Surgical Sciences, Royal Infirmary of Edinburgh, Edinburgh, Scotland (Drs Hendry and Fearon); Department of Anaesthesiology and Intensive Care Medicine, Campus Charite Mitte and Campus Virchow Klinikum, Charite Universitaetsmedizin Berlin, Berlin, Germany (Dr Spies); and Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre Biomedical Research Unit, Nottingham University Hospitals, Queens Medical Centre, Nottingham, England (Dr Lobo). Correspondence: Kristoffer Lassen, MD, PhD, Department of Gastrointestinal Surgery, University Hospital Northern Norway, 9038 Troms, Norway (lassen@unn .no). Author Contributions: Study concept and design: Lassen, Soop, Nygren, von Meyenfeldt, Fearon, Revhaug, Ljungqvist, Lobo, and Dejong. Acquisition of data: Lassen, Soop, Cox, Hendry, von Meyenfeldt, Norderval, and Dejong. Analysis and interpretation of data: Lassen, Nygren, Hendry, Spies, Fearon, Norderval, Ljungqvist, and Dejong. Drafting of the manuscript: Lassen, Soop, Nygren, Cox, Hendry, Fearon, Lobo, and Dejong. Critical revision of the manuscript for important intellectual content: Lassen, Soop, Spies, von Meyenfeldt, Fearon, Revhaug, Norderval, Ljungqvist, Lobo, and Dejong. Obtained funding: von Meyenfeldt, Revhaug, Ljungqvist, and Dejong. Administrative, technical, and material support: Lassen, Soop, Cox, Spies, von Meyenfeldt, Fearon, Revhaug, Ljungqvist, Lobo, and Dejong. Study supervision: Lassen, Soop, Nygren, Hendry, von Meyenfeldt, Revhaug, and Dejong. Enhanced Recovery After Surgery (ERAS) Group Members: Kristoffer Lassen, MD, PhD, Arthur Revhaug, MD, PhD, Stig Norderval, MD, PhD, University Hospital Northern Norway, Troms, Norway; Mattias Soop, MD, PhD, University of Auckland, Grafton, Auckland, New Zealand; Jonas Nygren, MD, PhD, Jonathan Hausel, MD, Ersta Hospital, Stockholm, Sweden; P. Boris W. Cox, MD, Maarten F. von Meyenfeldt, MD, PhD, Cornelis H. C. Dejong, MD, PhD, Jose Maessen, BSc, Ronald M. van Dam, MD, Maastricht University Medical Centre, Maastricht, the Netherlands; Paul O. Hendry, MBChB, MRCS, Kenneth C. H. Fearon, MD, FRCS, Royal Infirmary of Edinburgh, Edinburgh, Scotland; Claudia Spies, MD, PhD, Charite Universitaetsmedizin Berlin, Berlin, Germany; Olle Ljungqvist, MD, PhD, Karolinska University Hospital Huddinge, Stockholm, Sweden; Dileep N. Lobo, DM, FRCS, Nottingham Digestive Diseases Centre Biomedical Research Unit, Nottingham University Hospitals, Queens Medical Centre, Nottingham, England; Robin Kennedy, MD, St Marks Hospital, London, England. Financial Disclosure: Dr Ljungqvist is the owner of a patent for a preoperative carbohydrate-rich drink licensed to Danone/Nutricia, which produces and markets a drink based on this patent. Funding/Support: This work was supported by Fresenius Kabi, which has been sponsoring the ERAS Group with an unrestricted grant since 2006. Role of the Sponsor: Fresenius Kabi (or any other commercial company) has not participated in the research work, the discussions, the writing of the manuscript, or the decision to publish the work.
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REFERENCES
1. Basse L, Hjort Jakobsen D, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg. 2000;232(1): 51-57. 2. Basse L, Raskov HH, Hjort Jakobsen D, et al. Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg. 2002;89(4):446-453. 3. Wind J, Polle SW, Fung Kon Jin PH, et al; Laparoscopy and/or Fast Track Multimodal Management Versus Standard Care (LAFA) Study Group; Enhanced Recovery after Surgery (ERAS) Group. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg. 2006;93(7):800-809. 4. Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg. 2007; 245(6):867-872. 5. Nygren J, Hausel J, Kehlet H, et al. A comparison in five European Centres of case mix, clinical management and outcomes following either conventional or fast-track perioperative care in colorectal surgery. Clin Nutr. 2005;24(3): 455-461. 6. Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24(3):466-477. 7. Phillips B, Ball C, Sacket D, et al. Levels of Evidence and Grades of Recommendations. Oxford, England: Centre for Evidence Based Medicine; 2007. 8. Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R. Psychological influences on surgical recovery: perspectives from psychoneuroimmunology. Am Psychol. 1998;53(11):1209-1218. 9. Egbert LD, Battit G, Welch C, Bartlett M. Reduction of postoperative pain by encouragement and instruction of patients: a study of doctor-patient rapport. N Engl J Med. 1964;270:825-827. 10. Halaszynski TM, Juda R, Silverman DG. Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med. 2004; 32(4)(suppl):S76-S86. 11. Forster AJ, Clark HD, Menard A, et al. Effect of a nurse team coordinator on outcomes for hospitalized medicine patients. Am J Med. 2005;118(10):1148-1153. 12. Disbrow EA, Bennett HL, Owings JT. Effect of preoperative suggestion on postoperative gastrointestinal motility. West J Med. 1993;158(5):488-492. 13. Blay N, Donoghue J. The effect of pre-admission education on domiciliary recovery following laparoscopic cholecystectomy. Aust J Adv Nurs. 2005; 22(4):14-19. 14. Holte K, Nielsen KG, Madsen JL, Kehlet H. Physiologic effects of bowel preparation. Dis Colon Rectum. 2004;47(8):1397-1402. 15. Jung B, Pahlman L, Nystrm P-O, Nilsson E; Mechanical Bowel Preparation Study Group. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection. Br J Surg. 2007;94(6):689-695. 16. Contant CM, Hop WC, vant Sant HP, et al. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet. 2007; 370(9605):2112-2117. 17. Slim K, Vicaut E, Panis Y, Chipponi J. Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation. Br J Surg. 2004;91(9):1125-1130. 18. Wille-Jrgensen P, Guenaga KF, Castro AA, Matos D. Clinical value of preoperative mechanical bowel cleansing in elective colorectal surgery: a systematic review. Dis Colon Rectum. 2003;46(8):1013-1020. 19. Platell C, Hall J. What is the role of mechanical bowel preparation in patients undergoing colorectal surgery? Dis Colon Rectum. 1998;41(7):875-882, discussion 882-883. 20. Bucher P, Gervaz P, Soravia C, Mermillod B, Erne M, Morel P. Randomized clinical trial of mechanical bowel preparation vs no preparation before elective leftsided colorectal surgery. Br J Surg. 2005;92(4):409-414. 21. Ram E, Sherman Y, Weil R, Vishne T, Kravarusic D, Dreznik Z. Is mechanical bowel preparation mandatory for elective colon surgery? a prospective randomized study. Arch Surg. 2005;140(3):285-288. 22. Jung B, Lannerstad O, Pahlman L, Arodell M, Unosson M, Nilsson E. Preop erative mechanical preparation of the colon: the patients experience. BMC Surg. 2007;7:5. 23. Guenaga KF, Matos D, Castro AA, Atallah AN, Wille-Jrgensen P. Mechanical bowel preparation for elective colorectal surgery [update of: Cochrane Database Syst Rev. 2003;(2):CD001544]. Cochrane Database Syst Rev. 2005; (1):CD001544. 24. Platell C, Barwood N, Makin G. Randomized clinical trial of bowel preparation with a single phosphate enema or polyethylene glycol before elective colorectal surgery. Br J Surg. 2006;93(4):427-433.
25. Ljungqvist O, Sreide E. Preoperative fasting. Br J Surg. 2003;90(4):400-406. 26. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003;(4):CD004423. 27. Eriksson LI, Sandin R. Fasting guidelines in different countries. Acta Anaesthesiol Scand. 1996;40(8, pt 2):971-974. 28. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: a report by the American Society of Anesthesiologist Task Force on Preoperative Fasting. Anesthesiology. 1999;90(3): 896-905. 29. Sreide E, Eriksson LI, Hirlekar G, et al; Task Force on Scandinavian Preoperative Fasting Guidelines, Clinical Practice Committee Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Pre-operative fasting guidelines: an update. Acta Anaesthesiol Scand. 2005;49(8):1041-1047. 30. Sreide E, Fasting S, Raeder J. New preoperative fasting guidelines in Norway. Acta Anaesthesiol Scand. 1997;41(6):799. 31. Maltby JR, Pytka S, Watson NC, Cowan RA, Fick GH. Drinking 300 mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients. Can J Anaesth. 2004;51(2):111115. 32. Harter RL, Kelly WB, Kramer MG, Perez CE, Dzwonczyk RR. A comparison of the volume and pH of gastric contents of obese and lean surgical patients. Anesth Analg. 1998;86(1):147-152. 33. Kong MF, Horowitz M. Diabetic gastroparesis. Diabet Med. 2005;22(suppl 4): 13-18. 34. Breuer JP, von Dossow V, von Heymann C, et al. Preoperative oral carbohydrate administration to ASA III-IV patients undergoing elective cardiac surgery. Anesth Analg. 2006;103(5):1099-1108. 35. Hausel J, Nygren J, Lagerkranser M, et al. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Anesth Analg. 2001; 93(5):1344-1350. 36. Nygren J. The metabolic effects of fasting and surgery. Best Pract Res Clin Anaesthesiol. 2006;20(3):429-438. 37. Crowe PJ, Dennison A, Royle GT. The effect of pre-operative glucose loading on postoperative nitrogen metabolism. Br J Surg. 1984;71(8):635-637. 38. Svanfeldt M, Thorell A, Hausel J, et al. Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics. Br J Surg. 2007;94(11):1342-1350. 39. Yuill KA, Richardson RA, Davidson HIM, Garden OJ, Parks RW. The administration of an oral carbohydrate-containing fluid prior to major elective uppergastrointestinal surgery preserves skeletal muscle mass postoperatively: a randomised clinical trial. Clin Nutr. 2005;24(1):32-37. 40. Henriksen MG, Hessov I, Dela F, Hansen HV, Haraldsted V, Rodt SA. Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery. Acta Anaesthesiol Scand. 2003;47(2):191-199. 41. Nygren J, Thorell A, Ljungqvist O. Preoperative oral carbohydrate nutrition: an update. Curr Opin Clin Nutr Metab Care. 2001;4(4):255-259. 42. Noblett SE, Watson DS, Huong H, Davison B, Hainsworth PJ, Horgan AF. Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Dis. 2006;8(7):563-569. 43. Smith AF, Pittaway AJ. Premedication for anxiety in adult day surgery [update of: Cochrane Database Syst Rev. 2000;(3):CD002192]. Cochrane Database Syst Rev. 2003;(1):CD002192. 44. Smith AF, Pittaway AJ. Premedication for anxiety in adult day surgery. Cochrane Database Syst Rev. 2000;(3):CD002192. 45. Clagett GP, Anderson FA Jr, Geerts W, et al. Prevention of venous thromboembolism. Chest. 1998;114(5)(suppl):531S-560S. 46. Wille-Jrgensen P, Rasmussen MS, Andersen BR, Borly L. Heparins and mechanical methods for thromboprophylaxis in colorectal surgery [update of: Cochrane Database Syst Rev. 2001;(3):CD001217]. Cochrane Database Syst Rev. 2003;(4):CD001217. 47. Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin: overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med. 1988;318(18):1162-1173. 48. Clagett GP, Reisch JS. Prevention of venous thromboembolism in general surgical patients: results of meta-analysis. Ann Surg. 1988;208(2):227-240. 49. Koch A, Ziegler S, Breitschwerdt H, Victor N. Low molecular weight heparin and unfractionated heparin in thrombosis prophylaxis: meta-analysis based on original patient data. Thromb Res. 2001;102(4):295-309. 50. Koch A, Bouges S, Ziegler S, Dinkel H, Daures JP, Victor N. Low molecular weight heparin and unfractionated heparin in thrombosis prophylaxis after major surgical intervention: update of previous meta-analyses. Br J Surg. 1997;84 (6):750-759.
WWW.ARCHSURG.COM
51. Warkentin TE, Levine MN, Hirsh J, et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med. 1995;332(20):1330-1335. 52. McLeod RS, Geerts WH, Sniderman KW, et al; Canadian Colorectal Surgery DVT Prophylaxis Trial Investigators. Subcutaneous heparin vs low-molecularweight heparin as thromboprophylaxis in patients undergoing colorectal surgery: results of the Canadian Colorectal DVT Prophylaxis Trial: a randomized, double-blind trial. Ann Surg. 2001;233(3):438-444. 53. Antiplatelet Trialists Collaboration. Collaborative overview of randomised trials of antiplatelet therapy, III: reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients. BMJ. 1994;308(6923):235-246. 54. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest. 2001;119(1)(suppl):132S-175S. 55. Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med. 2003; 28(3):172-197. 56. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinalepidural anesthesia. Anesth Analg. 1994;79(6):1165-1177. 57. Bergqvist D, Lindblad B, Matzsch T. Risk of combining low molecular weight heparin for thromboprophylaxis and epidural or spinal anesthesia. Semin Thromb Hemost. 1993;19(suppl 1):147-151. 58. Song F, Glenny AM. Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomized controlled trials. Br J Surg. 1998;85(9):1232-1241. 59. Bratzler DW, Houck PM; Surgical Infection Prevention Guidelines Writers Workgroup; American Academy of Orthopaedic Surgeons; American Association of Critical Care Nurses; American Association of Nurse Anesthetists; American College of Surgeons; American College of Osteopathic Surgeons; American Geriatrics Society; American Society of Anesthesiologists; American Society of Colon and Rectal Surgeons; American Society of Health-System Pharmacists; American Society of Perianesthesia Nurses; Ascension Health; Association of Perioperative Registered Nurses; Association for Professionals in Infection Control and Epidemiology; Infectious Diseases Society of America; Medical Letter; Premier; Society for Healthcare Epidemiology of America; Society of Thoracic Surgeons; Surgical Infection Society. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38(12):1706-1715. 60. BMJ Group; Royal Pharmaceutical Society of Great Britain. British National Formulary 55. London, England: BMJ Group, RPS Publishing; 2008. 61. Miedema BW, Johnson JO. Methods for decreasing postoperative gut dysmotility. Lancet Oncol. 2003;4(6):365-372. 62. Uchida I, Asoh T, Shirasaka C, Tsuji H. Effect of epidural analgesia on postoperative insulin resistance as evaluated by insulin clamp technique. Br J Surg. 1988;75(6):557-562. 63. Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia: their role in postoperative outcome. Anesthesiology. 1995;82(6):1474-1506. 64. Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290(18): 2455-2463. 65. Jrgensen H, Wetterslev J, Miniche S, Dahl JB. Epidural local anaesthetics vs opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev. 2000; (4):CD001893. 66. Porter JS, Bonello E, Reynolds F. The influence of epidural administration of fentanyl infusion on gastric emptying in labour. Anaesthesia. 1997;52(12): 1151-1156. 67. Niemi G, Breivik H. The minimally effective concentration of adrenaline in a lowconcentration thoracic epidural analgesic infusion of bupivacaine, fentanyl and adrenaline after major surgery: a randomized, double-blind, dose-finding study. Acta Anaesthesiol Scand. 2003;47(4):439-450. 68. Niemi G, Breivik H. Epinephrine markedly improves thoracic epidural analgesia produced by a small-dose infusion of ropivacaine, fentanyl, and epinephrine after major thoracic or abdominal surgery: a randomized, double-blinded crossover study with and without epinephrine. Anesth Analg. 2002;94(6):1598-1605. 69. Niemi G, Breivik H. Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: a randomised, double-blind, cross-over study with and without adrenaline. Acta Anaesthesiol Scand. 1998;42(8):897-909. 70. van den Bosch JE, Bonsel GJ, Moons KG, Kalkman CJ. Effect of postoperative experiences on willingness to pay to avoid postoperative pain, nausea, and vomiting. Anesthesiology. 2006;104(5):1033-1039. 71. Gan T, Sloan F, Dear GL, El Moalem HE, Lubarsky DA. How much are patients willing to pay to avoid postoperative nausea and vomiting? Anesth Analg. 2001; 92(2):393-400.
72. Eberhart LH, Morin AM, Wulf H, Geldner G. Patient preferences for immediate postoperative recovery. Br J Anaesth. 2002;89(5):760-761. 73. Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? the perspective of patients. Anesth Analg. 1999; 89(3):652-658. 74. Apfel CC, Kranke P, Eberhart LH, Roos A, Roewer N. Comparison of predictive models for postoperative nausea and vomiting. Br J Anaesth. 2002;88(2): 234-240. 75. Rsch D, Eberhart L, Biedler A, Dethling J, Apfel CC. Prospective application of a simplified risk score to prevent postoperative nausea and vomiting. Can J Anaesth. 2005;52(5):478-484. 76. Carlisle JB, Stevenson CA. Drugs for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2006;3:CD004125. 77. Wallenborn J, Gelbrich G, Bulst D, et al. Prevention of postoperative nausea and vomiting by metoclopramide combined with dexamethasone: randomised double blind multicentre trial. BMJ. 2006;333(7563):324. 78. Tjandra JJ, Chan MK. Systematic review on the short-term outcome of laparoscopic resection for colon and rectosigmoid cancer. Colorectal Dis. 2006; 8(5):375-388. 79. Basse L, Jakobsen DH, Bardram L, et al. Functional recovery after open vs laparoscopic colonic resection: a randomized, blinded study. Ann Surg. 2005; 241(3):416-423. 80. King PM, Blazeby JM, Ewings P, et al. Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg. 2006;93(3):300-308. 81. Wind J, Hofland J, Preckel B, et al. Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management vs standard care (LAFA trial). BMC Surg. 2006;6:16. 82. Grantcharov TP, Rosenberg J. Vertical compared with transverse incisions in abdominal surgery. Eur J Surg. 2001;167(4):260-267. 83. Lindgren PG, Nordgren SR, Oresland T, Hulten L. Midline or transverse abdominal incision for right-sided colon cancer: a randomized trial. Colorectal Dis. 2001;3(1):46-50. 84. Brown SR, Goodfellow PJ, Adam IJ, Shorthouse AJ. A randomised controlled trial of transverse skin crease vs vertical midline incision for right hemicolectomy. Tech Coloproctol. 2004;8(1):15-18. 85. Greenall MJ, Evans M, Pollock AV. Midline or transverse laparotomy? a random controlled clinical trial, part II: influence on postoperative pulmonary complications. Br J Surg. 1980;67(3):191-194. 86. Brown SR, Goodfellow PB. Transverse vs midline incisions for abdominal surgery. Cochrane Database Syst Rev. 2005;(4):CD005199. 87. ODwyer PJ, McGregor JR, McDermott EW, Murphy JJ, OHiggins NJ. Patient recovery following cholecystectomy through a 6 cm or 15 cm transverse subcostal incision: a prospective randomized clinical trial. Postgrad Med J. 1992; 68(804):817-819. 88. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective vs routine nasogastric decompression after elective laparotomy. Ann Surg. 1995;221(5):469-476, discussion 476-478. 89. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery [update of: Cochrane Database Syst Rev. 2005;(1):CD004929]. Cochrane Database Syst Rev. 2007;(3):CD004929. 90. Manning BJ, Winter DC, McGreal G, Kirwan WO, Redmond HP. Nasogastric intubation causes gastroesophageal reflux in patients undergoing elective laparotomy. Surgery. 2001;130(5):788-791. 91. Kurz A, Sessler DI, Lenhardt R; Study of Wound Infection and Temperature Group. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med. 1996;334(19):1209-1215. 92. Scott EM, Buckland R. A systematic review of intraoperative warming to prevent postoperative complications. AORN J. 2006;83(5):1090-1104, 1107-1113. 93. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events: a randomized clinical trial. JAMA. 1997;277(14):1127-1134. 94. Nesher N, Zisman E, Wolf T, et al. Strict thermoregulation attenuates myocardial injury during coronary artery bypass graft surgery as reflected by reduced levels of cardiac-specific troponin I. Anesth Analg. 2003;96(2):328-335. 95. Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet. 1996;347(8997):289-292. 96. Wong PF, Kumar S, Bohra A, Whetter D, Leaper DJ. Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg. 2007;94(4):421-426. 97. Hannemann P, Lassen K, Hausel J, et al. Patterns in current anaesthesiological peri-operative practice for colonic resections: a survey in five northernEuropean countries. Acta Anaesthesiol Scand. 2006;50(9):1152-1160. 98. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of
WWW.ARCHSURG.COM
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359(9320):18121818. Tambyraja AL, Sengupta F, MacGregor AB, Bartolo DCC, Fearon KCH. Patterns and clinical outcomes associated with routine intravenous sodium and fluid administration after colorectal resection. World J Surg. 2004;28(10):10461051, discussion 1051-1052. Brandstrup B, Tonnesen H, Beier-Holgersen R, et al; Danish Study Group on Perioperative Fluid Therapy. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003;238(5):641648. Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology. 2005;103(1):25-32. MacKay G, Fearon K, McConnachie A, Serpell MG, Molloy RG, ODwyer PJ. Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery. Br J Surg. 2006;93(12): 1469-1474. Holte K, Foss NB, Svensen C, Lund C, Madsen JL, Kehlet H. Epidural anesthesia, hypotension, and changes in intravascular volume. Anesthesiology. 2004; 100(2):281-286. Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002; 97(4):820-826. Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia. 2002; 57(9):845-849. Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95(5):634-642. Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93(9):1069-1076. Walsh SR, Tang T, Bass S, Gaunt ME. Doppler-guided intra-operative fluid management during major abdominal surgery: systematic review and meta-analysis. Int J Clin Pract. 2008;62(3):466-470. Karliczek A, Jesus EC, Matos D, Castro AA, Atallah AN, Wiggers T. Drainage or nondrainage in elective colorectal anastomosis: a systematic review and meta-analysis. Colorectal Dis. 2006;8(4):259-265. Jesus EC, Karliczek A, Matos D, Castro AA, Atallah AN. Prophylactic anastomotic drainage for colorectal surgery. Cochrane Database Syst Rev. 2004; (4):CD002100. Peeters KC, Tollenaar RA, Marijnen CA, et al; Dutch Colorectal Cancer Group. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg. 2005;92(2):211-216. McPhail MJ, Abu-Hilal M, Johnson CD. A meta-analysis comparing suprapubic and transurethral catheterization for bladder drainage after abdominal surgery. Br J Surg. 2006;93(9):1038-1044. Basse L, Werner M, Kehlet H. Is urinary drainage necessary during continuous epidural analgesia after colonic resection? Reg Anesth Pain Med. 2000;25 (5):498-501. Marret E, Remy C, Bonnet F; Postoperative Pain Forum Group. Meta-analysis of epidural analgesia vs parenteral opioid analgesia after colorectal surgery. Br J Surg. 2007;94(6):665-673. Hansen CT, Sorensen M, Moller C, Ottesen B, Kehlet H. Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double-blind, placebo-controlled randomized study. Am J Obstet Gynecol. 2007;196(4): 311.e1-311.e7. Basse L, Madsen JL, Kehlet H. Normal gastrointestinal transit after colonic resection using epidural analgesia, enforced oral nutrition and laxative. Br J Surg. 2001;88(11):1498-1500. Delaney CP, Wolff BG, Viscusi ER, et al. Alvimopan, for postoperative ileus following bowel resection: a pooled analysis of phase III studies. Ann Surg. 2007; 245(3):355-363. Zutshi M, Delaney CP, Senagore AJ, et al. Randomized controlled trial comparing the controlled rehabilitation with early ambulation and diet pathway vs the controlled rehabilitation with early ambulation and diet with preemptive epidural anesthesia/analgesia after laparotomy and intestinal resection. Am J Surg. 2005;189(3):268-272. Rigg JR, Jamrozik K, Myles PS, et al; MASTER Anaethesia Trial Study Group. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet. 2002;359(9314):1276-1282.
120. Low J, Johnston N, Morris C. Epidural analgesia: first do no harm. Anaesthesia. 2008;63(1):1-3. 121. Fedder A, Dall R, Laurberg S, Rodt SA. Epidural anaesthesia with bupivacaine does not cause increased oedema in small gut anastomoses in pigs. Eur J Anaesthesiol. 2004;21(11):864-870. 122. Gould TH, Grace K, Thorne G, Thomas M. Effect of thoracic epidural anaesthesia on colonic blood flow. Br J Anaesth. 2002;89(3):446-451. 123. Woolsey CA, Coopersmith CM. Vasoactive drugs and the gut: is there anything new? Curr Opin Crit Care. 2006;12(2):155-159. 124. Thoren A, Elam M, Ricksten SE. Differential effects of dopamine, dopexamine, and dobutamine on jejunal mucosal perfusion early after cardiac surgery. Crit Care Med. 2000;28(7):2338-2343. 125. Seguin P, Laviolle B, Guinet P, Morel I, Malledant Y, Bellissant E. Dopexamine and norepinephrine vs epinephrine on gastric perfusion in patients with septic shock: a randomized study [NCT00134212]. Crit Care. 2006;10(1):R32. 126. Meier-Hellmann A, Sakka SG, Reinhart K. Catecholamines and splanchnic perfusion. Schweiz Med Wochenschr. 2000;130(50):1942-1947. 127. Meier-Hellmann A, Reinhart K, Bredle DL, Sakka SG. Therapeutic options for the treatment of impaired gut function. J Am Soc Nephrol. 2001;12(suppl 17): S65-S69. 128. Cepeda MS, Carr DB, Miranda N, Diaz A, Silva C, Morales O. Comparison of morphine, ketorolac, and their combination for postoperative pain: results from a large, randomized, double-blind trial. Anesthesiology. 2005;103(6):12251232. 129. Andersen J, Hjort-Jakobsen D, Christiansen PS, Kehlet H. Readmission rates after a planned hospital stay of 2 vs 3 days in fast-track colonic surgery. Br J Surg. 2007;94(7):890-893. 130. Hedner T, Samulesson O, Wahrborg P, Wadenvik H, Ung KA, Ekbom A. Nabumetone: therapeutic use and safety profile in the management of osteoarthritis and rheumatoid arthritis. Drugs. 2004;64(20):2315-2343, discussion 23442345. 131. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal surgery vs later commencement of feeding for postoperative complications. Cochrane Database Syst Rev. 2006;(4):CD004080. 132. Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding vs nil by mouth after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ. 2001;323(7316):773-776. 133. Han-Geurts IJ, Hop WC, Kok NF, Lim A, Brouwer KJ, Jeekel J. Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery. Br J Surg. 2007;94(5):555-561. 134. Watters JM, Kirkpatrick SM, Norris SB, Shamji FM, Wells GA. Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased mobility. Ann Surg. 1997;226(3):369-377, discussion 377-380. 135. Charoenkwan K, Phillipson G, Vutyavanich T. Early vs delayed (traditional) oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev. 2007;(4):CD004508. 136. Beattie AH, Prach AT, Baxter JP, Pennington CR. A randomised controlled trial evaluating the use of enteral nutritional supplements postoperatively in malnourished surgical patients. Gut. 2000;46(6):813-818. 137. Keele AM, Bray MJ, Emery PW, Duncan HD, Silk DB. Two phase randomised controlled clinical trial of postoperative oral dietary supplements in surgical patients. Gut. 1997;40(3):393-399. 138. Smedley F, Bowling T, James M, et al. Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care. Br J Surg. 2004;91(8):983-990. 139. Fearon KC, Luff R. The nutritional management of surgical patients: enhanced recovery after surgery. Proc Nutr Soc. 2003;62(4):807-811. 140. Henriksen MG, Hansen HV, Hessov I. Early oral nutrition after elective colorectal surgery: influence of balanced analgesia and enforced mobilization. Nutrition. 2002;18(3):263-267. 141. Soop M, Carlson GL, Hopkinson J, et al. Randomized clinical trial of the effects of immediate enteral nutrition on metabolic responses to major colorectal surgery in an enhanced recovery protocol. Br J Surg. 2004;91(9):1138-1145. 142. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630-641. 143. Lassen K, Hannemann P, Ljungqvist O, et al; Enhanced Recovery After Surgery Group. Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ. 2005;330(7505):14201421. 144. Maessen J, Dejong CH, Hausel J, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007; 94(2):224-231. 145. Urbach DR, Baxter NN. Reducing variation in surgical care. BMJ. 2005;330(7505): 1401-1402.
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AAGBI Enhanced Recovery Seminar April 2010

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Anaesthesia, Goal Directed Therapy and Enhanced Recovery for Colorectal Surgery

Simplified Enhanced Recovery in Laparoscopic Colorectal Surgery Trimodal Model

Enhanced Recovery Protocol

Individualised Fluid Therapy Effective Analgesia

Early Gut Function

Modulation of stress response

Simplified Enhanced Recovery in Laparoscopic Colorectal Surgery Trimodal Model

Early Gut Function

Modulation of stress response

Decreased Complications Healing

Decreased Length of Stay

Thesecomponentscombinedwithearlymobilityleadtoearlyfeedingandgutfunction.Thisinturnhelpsto modulatethestressresponseandpromoteshealing.Reducedcomplicationsandsecondaryinfectionleadtoa decreasedlengthofstay.

Overview of Enhanced Recovery In Colorectal Surgery

Enhanced Recovery Partnership Programme

Cancer Action Team

Example of enhanced recovery elements

Why is Colorectal surgery well suited to an ER program?

23 Hour Stay Laparoscopic Colectomy

Enhanced Recovery Model

Day by Day Summary

Challenging established concepts

Key Points for optimal outcome from major open surgery

Enhanced Recovery Model

Simplified Enhanced Recovery in Laparoscopic Colorectal Surgery Trimodal Model

Enhanced Recovery Protocol

Individualised Fluid Therapy Effective Analgesia

Early Gut Function

Modulation of stress response

Simplified Enhanced Recovery in Laparoscopic Colorectal Surgery Trimodal Model

Analgesia: Open v Laparoscopic

Early Gut Function

Modulation of stress response

Decreased Complications Healing

Decreased Length of Stay

Laparoscopic colorectal surgery

Minimally Invasive Surgery Maximum cardiopulmonary stress

Laparoscopic colorectal surgery

Which is the optimal stress response?

Epidural group in hospital

Spinal group at home

Perioperative care Pathways

ERAS results by age

3 Groups of Patients: No co morbidities Major co morbidities Elderly (with or without co-morbidities)

In Patient Care Pathways

ER - Whats it all about?

Whats it really all about: survival

Colon Column2 Rectum Column3

Which is the optimal stress response?

Epidural group in hospital

Spinal group at home

Enhanced Recovery Partnership Programme

Analgesia for open and laparoscopic surgery

Cancer Action Team

Consultant in Anaesthesia and Intensive Care Medicine

Colorectal Surgery Model Analgesia for open surgery

Part of multimodal approach to postoperative recovery

Benefits of neuroaxial block

Epidurals and colorectal surgery

Also reductions in myocardial infarction and renal failure

Balanced or Multimodal analgesia

Problems with analgesia

How good are epidurals?

Hypotension Poor mobility Neurological damage Up to 50% dont work adequately