What is "Enhanced ercovery" in the context of colorectal surgery?

 

Site http://www.thedukesclub.org.uk/phpBB2/viewtopic.php?t=144

 

 

            This is vital. Like Antenatal classes it improves outcome through education of what is to come. This removes a lot of fears and anxiety about the surgery and the expectation are brought in line with the expected care pathway. Carbohydrate treatment instead of overnight fasting before surgery has been shown to reduce postoperative insulin resistance and to reduce hospital stay approximately 20% after elective surgery

 

Education of patient and relatives Improves the number of people to adhere to the planned care pathway Can help discharge planning ( Pre admission!!) with verbal contracts with patients and relatives

 

 

 

 

 

There is no evidence to support its use. However some will still give enemas pre op. Evidence for/ against this can be found and interpreted either way. It causes dehydration and electrolyte imbalance It isn’t pleasant causing stress & anxiety.

 

References:

 

 

 

Increase atelectasis, reflux and pneumonia Drains should be omitted after hepatic, colonic, or rectal resection with primary anastamosis and appendectomy for any stage of appendicitis (recommendation grade A),

 

 

 

Conflicting studies Provide good analgesia but little other evidence to support its routine use.

 

 

 

Day case type anaesthetic with short acting agents – propofol, ramifentanil Minimal iv fluids in theatre. Early ambulation and oral intake …even in recovery can improve outcome.

 

 

 

No bowel prep Use of vasopressors rather than flooding patient with fluids in epidural induced hypotension Balance of tissue perfusion vs overloading can be helped with trans oesophageal Doppler Aim to get ivi down day 1

 

Cochrane http://www.cochrane.org/reviews/en/ab005199.html

 

 

This reduces metabolic / endocrine response Avoids coagulopathy Lower wound complications

 

 

 

Mobilisation avoids chest complications, DVT, loss of muscle bulk and catabolism. Avoid HDU / ITU as this impedes the above. Effective analgesia Pre op counselling can help patients stick to the agreed post op care pathway Sit out for > 2hrs day 1 Sat out dressed day 2 Assisted 60metre walks TWOC day 1 colonic , day 3 rectal resections

 

 

Mobilisation avoids chest complications, DVT, loss of muscle bulk and catabolism. Avoid HDU / ITU as this impedes the above. Effective analgesia in the form of epidural is better than a PCA. ( this could change with single one off spinals) Avoid opiates + give effective anti emetics (Ondansetron) Regular Paracetamol and NSAID’s Pre op counselling can help patients stick to the agreed post op care pathway

 

 

 

If ANY of the above are not missing the enhanced recovery will be suboptimal There needs to be trained members of a dedicated ward The population has important influences. Ethnic, social and age related factors change the ability for an enhanced recovery program to work Discharge planning. Without support form your local GP’s and nurses patients will readily bounce back.

 

 

 

Further referenced material 2005

http://www.health.wa.gov.au/hrit/clinicalplanning/docs/ERASfastTrackSurg.pdf

 Other papers that you need to be aware of....

Linda Basse et al Colonic surgery with accelerated rehablitation or conventional care. Dis Colon Rectum 2004;47:271-278

King et al ( Robin Kennedy paper) RCT comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. BJS 2006;93:300-308