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ERAS Overview

Enhanced Recovery After Surgery Shelly Cannon MSN, RN, AGCNS – BC, CPAN, RN-BC (Pain) April 2019 DAORN. ERAS Overview . The ERAS Society was developed in 2001 by European surgeons

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ERAS Overview

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  1. Enhanced Recovery After SurgeryShelly Cannon MSN, RN, AGCNS – BC, CPAN, RN-BC (Pain)April 2019DAORN

  2. ERAS Overview • The ERAS Society was developed in 2001 by European surgeons • Studies demonstrated variable perioperative care across Northern Europe with minimal adoption of evidence based practice • Key endpoint was quality of recovery, not speed • Primarily accomplished by reducing the metabolic response to surgical insult 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); 1420-1421

  3. Rationale of ERAS • Surgical patients travel from the surgeon’s office to preoperative clinics, PCPs, pre-op, the operating room, PACU and then postoperative wards • Staff in each facility focuses on managing the immediate clinical situation with little opportunity for strategic thinking • 24 core elements of ERAS care have scientific support and are distributed along the patient pathway • Delivered by different departments and clinicians as part of a comprehensive program

  4. ERAS Components • Preadmission • Cessation of smoking and excessive alcohol • Nutritional screening and support if needed • Medical optimization of chronic disease • Preoperative • Education and patient engagement • Carbohydrate treatment • Thrombosis prophylaxis • Infection prophylaxis • Nausea/vomiting prophylaxis Gustafsson U, Scott M, Schwenk W, et al; Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg (2013) 37:259-284

  5. ERAS Components • Intraoperative • Minimal invasive surgical technique • Avoid long acting opioids • Maintain fluid balance; avoid hypo and hypervolemia. Vasopressors for BP control • Epidural anesthesia for open procedures • Restrictive use of surgical drains • Removal of NG tubes • Maintain normothermia Gustafsson U, Scott M, Schwenk W, et al; Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg (2013) 37:259-284

  6. ERAS Components • Postoperative • Early mobilization (day of surgery) • Early intake of oral fluids and solids (day of surgery) • Early removal of foleys and early discontinuation of IV fluids • Use of gum chewing, laxatives and peripheral opioid blocking agents • Intake of protein and energy-rich nutritional supplements • Multimodal approach to opioid sparing pain control • Multimodal approach to control of nausea and vomiting • Prepare for early discharge • Audit of outcomes in multi-disciplinary teams on regular basis Gustafsson U, Scott M, Schwenk W, et al; Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg (2013) 37:259-284

  7. Insulin Resistance • Insulin is the most important anabolic hormone in the body • Promotes overall anabolic reactions for fat, protein and carbohydrates • Under normal conditions, insulin is released from the pancreas in response to the intake of nutrients to promote energy storage • Resistance to the effects of insulin happen shortly after injury • Most notable among the effects of this is a decrease in the inhibitory effect of insulin on protein catabolism • Protein breaks down • Loss of muscle strength • Cellular dysfunction Thorell, A, Ngren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. CurrOpinClinNutrMetab Care 1999 2:69-78

  8. Insulin Resistance • Surgery is a deliberate injury to the body resulting in a neuroendocrine response and the release of stress hormones, and activation of cytokines and immune reactions • Insulin sensitive cells (most notably muscle) take up less glucose • Decreased energy • Increased circulating glucose levels • Non-insulin sensitive cells (immune cells, endothelial cells, neural cells) take up additional glucose because they respond to serum levels • Unable to store glucose so they undergo glycolysis resulting in • Increase in oxygen free radicals • Change in gene expression • Enhancement of inflammation Thorell, A, Ngren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. CurrOpinClinNutrMetab Care 1999 2:69-78

  9. Insulin Resistance • Cellular changes in these tissues result in • Infection (immune cells) • Cardiovascular complications (endothelial cells) • Neuropathy (neural cells) • These changes are sustained for prolonged periods of time • 2-3 weeks for a medium sized abdominal surgery like an open chole Thorell, A, Ngren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. CurrOpinClinNutrMetab Care 1999 2:69-78

  10. Avoiding Insulin Resistance with ERAS • Preoperative nutritional support • Carbohydrate loading • Epidural/spinal analgesia • Anti-inflammatory drugs • Early feeding • Optimal pain control Ljungqvist O. Jonathan E. Rhoads Lecture 2011: Insulin Resistance and Enhanced Recovery After Surgery. Journal of Parenteral and Enteral Nutrition. Volume 36 Number 4. July 2012 389-398

  11. Fluid Management • Pre-Operative • Clear fluids 2hrs before surgery including 45g carbs • Avoid replacing ”fluid losses” from bowel prep • Avoid hyper-osmotic or hypo-osmotic bowel prep • Intra-Operative • Apply a goal directed fluid therapy (GDFT) approach to fluid management • Use advanced hemodynamic monitoring • Oliguria in isolation should not trigger fluid therapy • Avoid treating every instance of hemodynamic change with fluid administration • Treat relative hypovolemia (vasodilation) with vasopressors • Recommend crystalloid rather than starch solutions • Post-Operative • Allow unrestricted access to oral fluids • Apply similar hemodynamic framework to post-op care in critically ill patients Thiele R, Raghunathan K et al; American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioprative fluid management within an enhanced recovery pathway for colorectal surgery. Perioperative Medicine (2016) 5:24

  12. Fluid Management • Complicated topic • Bottom line • Hypovolemia is bad • Hypervolemia is bad • Euvolemia is good • Each hospital should make an effort to implement a GDFT protocol

  13. ERAS Benefits • Fewer complications • 2010 Meta-analysis of colorectal patients demonstrated a 50% reduction in complications when ERAS protocols were implemented • Highlighted the importance of compliance and showed the better the compliance to the protocol, the better the outcome • Shorter length of stay • Reduced cost • Variable reports but savings of thousands of dollars per patient is common • Lower mortality • Study of 4500 TJR patients showed significantly lower 2 year mortality with ERAS • Report of 900 patients with colorectal cancer showed ERAS patients with compliance >70% had 42% reduction in mortality vs those with compliance <70% Varadhan KK et al. ClinNutr. 2010; 29(4): 434-440 Gustafsson U et al. Arch Surg. 2011; 146(5); 571-577 Savaridas T et al. ActaOrthop. 2013; 84(1): 40-43 ERAS Compliance Group. Ann Surg 2015: 261(6): 1153-1159 Gustaffson U et al. World J Surg. 2016; 40(7): 1741-1747

  14. Opioids and Multimodal Pain Management

  15. What’s the harm with opioids? • Stimulate receptors in the brainstem to cause nausea & vomiting • Stimulate receptors in the gut to block motility and delay gastric emptying • Over sedate and/or contribute to delirium • Decrease the respiratory drive, leading to shallow breathing, hypoxemia, pneumonia • Tolerance, dependence, national crisis Scott MJ, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand. 2015

  16. Multimodal Medicines – Pre-emptive Analgesia • Acetaminophen ~ Scheduled • Ketorolac 30mg IV q 6hrs x 2 days OR celebrex 400mg PO BID x 3 days. Renal adjustment if necessary (Toradol 15mg or Celebrex 100mg) • For patients unable to take NSAIDs: TraMADol 50-100mg q4h prn • Gabapentin 100mg – 300mg PO TID or Daily • Oxycodone or Dilaudid as needed for breakthrough

  17. Oral vs. IV Tylenol? • Ubiquitous central-acting non-opioid analgesic, available in PO/PR/IV • Systematic Review published in 2015 • Six randomized trials compared PO to IV for efficacy, safety, pharmacokinetic outcome • There were obvious differences in bioavailability and time to efficacy (IV works faster with higher plasma levels and better for acute pain) Jibril F et al. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision Making. Can J Hosp Pharm. 2015;68(3):238-47

  18. “Why is anesthesia always bugging me about giving Toradol?” • Very effective non-opioid analgesic, particularly for intra-abdominal visceral pain • Minimal systemic risk if dosed appropriately • Renal dosing • Age appropriate dosing • Time limited (4 doses postop)

  19. Surgical risk of Toradol • Nonsteroidal Anti-inflammatory Drugs and the Risk for Anastomotic Failure: A Report From Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP) • Hakkarainen TW et al. JAMA Surg. 2015;150(3):223-228 • Bariatric & Colorectal surgeries with anastomosis • 13,082 patients, 3158 received NSAIDs • 90 day anastomosis leak rate 4.8% in NSAID group, 4.2% in controls (P = NS) • In non-elective cases, leak rate 12.3% in NSAID group, 8.3% in controls (P = 0.01) • Specific NSAIDs, doses, and timing were not determined • “…future evaluations should consider specific formulations, the dose effect, mechanism, and other relevant outcome domains, including pain control, cardiac complications, and overall recovery.”

  20. . What about postop bleeding and Toradol? • Gobble RM, Hoang HL, Kachniarz B, Orgill DP. Ketorolac does not increase perioperative bleeding: a meta-analysis of randomized controlled trials. PlastReconstr Surg. 2014 Mar;133(3):741-55. • 27 studies of 2314 patients: neurosurgical, abdominal, urologic, and orthopedic procedures, and endoscopies • No effect • Lewis SR, Nicholson A, Cardwell ME, Siviter G, Smith AF. Nonsteroidal anti-inflammatory drugs and perioperative bleeding in pediatric tonsillectomy. • Cochrane Database Syst Rev. 2013 Jul 18;7:CD003591 • No effect

  21. What about Celebrex? • Selective COX-2 inhibitor • Unlike Vioxx, wasn’t associated with increased cardiovascular risk in elderly • Does not effect platelet aggregation • Does not effect gastric mucosa

  22. COX-1 affinity (bottom) vs. COX-2 affinity (top) Determinable log [IC80 ratio (WBA-COX-2/COX-1)] rofecoxib > 50-fold COX-2 selective etodolac meloxicam celecoxib 5 to 50-fold COX-2 selective diclofenac < 5-fold COX-2 selective sulindac sodium salicylate ibuprofen naproxen aspirin indomethacin ketorolac 1 2 -1 3 -3 -2 0 log [IC80 ratio (WHMA COX-2/COX-1) Warner TD, et al., Proc. Natl. Acad. Sci.1999; 96,:7563-7568

  23. Entereg • Entereg (alvimopan) • Peripherally acting Mu receptor antagonist • Purported to accelerate time to GI recovery • First dose 12mg PO in pre-op, then BID post-op until return of normal bowel function (7 days or less) • Contraindicated in chronic opioid users, ESRD, complete GI obstruction, pancreatic or gastric anastomosis • $75/dose

  24. “Reverse skin wheal” midline wound injection Surgeon infiltration of long-acting local, in these planes along each side of midline incision Rahim & Ahmad. Malaysian SocAnesth 2016

  25. Liposomal bupivacaine (Exparel) technique http://www.exparel.com/hcp/resources/videos.shtml

  26. Exparel: evidence • Candiotti KA et al. Liposome Bupivacaine for Postsurgical Analgesia in Adult Patients Undergoing Laparoscopic Colectomy: Results from Prospective Phase IV Sequential Cohort Studies Assessing Health Economic Outcomes. CurrTher Res 2014; 76:1-6. “CONCLUSIONS: Compared with intravenous opioid PCA, a liposome bupivacaine-based multimodal analgesia regimen reduced postsurgical opioid use, hospital length of stay, and ORAEs, and may lead to improved postsurgical outcomes following laparoscopic colectomy.”  • Cohen SM. Extended pain relief trial utilizing infiltration of Exparel(R), a long-acting multivesicular liposome formulation of bupivacaine: a Phase IV health economic trial in adult patients undergoing open colectomy. J Pain Res 2012; 5:267-72. “CONCLUSION: This study confirmed that a liposomal bupivacaine-based multimodal analgesic regimen resulted in less opioid consumption, lower hospital costs, and a shorter length of stay than a standard opioid-based analgesic regimen for postsurgical pain in patients undergoing open colectomy.” • Marcet JE et al. An extended pain relief trial utilizing the infiltration of a long-acting MultivesicularliPosomefoRmulation Of bupiVacaine, EXPAREL (IMPROVE): a Phase IV health economic trial in adult patients undergoing ileostomy reversal. J Pain Res 2013; 6:549-55. “CONCLUSION: A liposome bupivacaine-based multimodal analgesic regimen resulted in statistically significant and clinically meaningful reductions in opioid consumption, shorter length of stay, and lower inpatient costs than an IV opioid-based analgesic regimen.” • Vogel JD. Liposome bupivacaine (EXPAREL) for extended pain relief in patients undergoing ileostomy reversal at a single institution with a fast-track discharge protocol: an IMPROVE Phase IV health economics trial. J Pain Res 2013;6:605-10. “CONCLUSION: A liposome bupivacaine-based multimodal analgesic regimen reduced postoperative opioid consumption in patients undergoing ileostomy reversal under a fast-track discharge protocol. A reduction of 21% in LOS (0.8 days) was noted which, although not statistically significant, may be considered clinically meaningful given the already aggressive fast-track discharge program.”

  27. Additional Pain Management Options Low-Dose Ketamine Infusion

  28. Lidocaine IV infusion for pain? • Bolus lidocaine used everyday in anesthesia • Blunts excitatory & inflammatory neural signaling • Blocks priming of neutrophils (inhibiting systemic inflammatory responses: cytokines & oxidative stress) • More effective for visceral pain • Reduces opioids • Speeds return of bowel, decreases postop ileus • Dunn LK, Durieux ME. Perioperative Use of Intravenous Lidocaine. Anesthesiology. 2017 • Kranke P, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev. 2015

  29. Anesthesia & analgesia, summarized • Preoperative oral multi-modal meds • Opioid-free thoracic epidural (TEA) or anesthesia placed TAPs - infiltration of plane between peritoneum & rectus sheath • Intraoperative opioid, ketamine, NSAID • Lidocaine drip begun in OR, continued 24 hr, renewable • Postoperative nausea and vomiting prophylaxis • Judicious fluid management, not “flooded” • Gum in PACU • Advance diet as tolerated • Ambulate on day of surgery • Foley discouraged or removed ASAP Liu VX, et al. Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System. JAMA Surg. 2017

  30. Magnesium • Peri-operative intravenous magnesium reduces opioid consumption, and to a lesser extent, pain scores, in the first 24 h postoperatively, without any reported serious adverse effects. • Analgesic properties of magnesium are believed to stem from regulation of calcium influx into the cell and antagonism of N-methyl-D-aspartate (NMDA) receptors in the central nervous system Magnesium2-5 g (30-50 mg/kg), possibly in 2 gram/hour repeat boluses For painrul cases – 10-20 mg/kg/hr continued in PACU Less painful cases – induction only, followed by boluses • Albrecht, E. , Kirkham, K. R., Liu, S. S. and Brull, R. (2013), Peri‐operative intravenous administration of magnesium sulphate and postoperative pain: a meta‐analysis. Anaesthesia, 68: 79-90

  31. Multi-modal analgesia New Model, laparoscopy or epidural contraindicated ...standardized interventions that may have modest impact in isolation, but synergistic benefit Wick EC, et al. Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg. 2017

  32. Multi-modal analgesia New Model, open laparotomy Wick EC, et al. Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg. 2017

  33. . Postop • No PCA  • Ketorolac 15-30mg IV q 6hrs x 2 days OR Celebrex 400mg PO BID x 3 days. Renal adjustment if necessary • Scheduled acetaminophen • Gabapentin 600mg PO BID x 3 days • Gum and clear fluids given in PACU • Diet resumed POD 0. Advanced as tolerated • Ensure supplementation • TKO IVF when PO intake is adequate • Mag-Ox 400mg PO BID with food • OOB POD 0 (may try to start this in PACU) • 4-6hrs/day ambulation • No NG tubes • Foley out POD 1 • PONV treatment; ondansetron, phenergan, benadryl, Compazine, Scopalomineetc • Entereg until bowel function returns • Do not chase low urine output with IVF • Tolerate moderate hypotension (MAP >50) if no signs of dizziness, confusion, CP/SOB etc

  34. Thank you!

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