Universitatea de Medicină și Farmacie

„Grigore T. Popa” Iași

Anesthesia for colo-rectal surgery.

The ERAS protocol

Prof. dr. Ioana Grigoras

„Grigore T. Popa” University of Medicine and Pharmacy Iasi
Anesthesia and Intensive Care Department
Regional Institute of Oncology Iasi

Cursul CEEA, Chișinău, 2017

 History of ERAS
 "fast track" concept to major abdominal surgery
 pioneered by Professor Henrik Kehlet, a colorectal surgeon
from the Hvidovre University Hospital in Denmark

https://sites.google.com/site/enhancedrecoveryaftersurgery/history-of-eras
 Conventional surgery
prolonged preoperative fasting

laxatives repeated enema

iv fluid overload nausea and vomiting

tubes sedation

drains opiod-based analgesia

prolonged ileus bed imobilization

prolonged postoperative fasting

 Fast-track surgery

no colon preparation
preoperative sweet drink
thoracic epidural

minimally
non-opioid analgetics
invasive surgery

no drains iv fluids restriction

no nasogastric tube
early mobilization
early enteral nutrition
 ERAS principles

• therapeutical approach based on pathophysiological mechanisms

minimizing surgical stress
minimizing surgical stress reaction
• patient-oriented therapeutical approach
reduced morbidity
accelerated postoperative recovery
shortening of LOS
family/professional reinsertion
• economical effects
Reduced costs
What is ERAS ?
Standardized protocol for perioperative care

 Multi-modal intervention
Days Weeks
 Reduce operative stress

Functional capacity
 Support organ function

 Reduced morbidity
Traditional Care
 Accelerate convalescence Enhanced Recovery

Henrik Kehlet, Br J Anaesth 1997; 78 : 606

What is ERAS ?
Standardized protocol for perioperative care
What is ERAS ?
Standardized protocol for perioperative care

Multi-modal intervention

preop stress pain exercise enteral

information attenuation relief nutrition

nurses surgeons anesthesists kinesitherapist dietician

Multi-disciplinary approach

Henrik Kehlet, Br J Anaesth 1997; 78 : 606

 Outline

 Anesthetist approach
 Surgeon approach
 Protocolization
 Outline

 Anesthetist approach
 Surgeon approach
 Protocolization
 Enhanced Recovery in practice
• Fluid management
Referral from
• Postoperativ glycaemic control
Primary Care
• Postoperative nutrition
• Early mobilisation
Pre- • Rapid hydration / nourishment
Operative • Appropriate iv therapy
• Catheters removed early
• Regular oral analgesia
• Optimised Admission • Avoid opiates
medical
conditions
• Nutrition Operative
• Fasting time
• Carbohidrate
drinking • Antimicrobial Post-
• Pre-anesthestic prophylaxis Operative
medication • Multimodal analgesia
• Anti-thrombotic • PONV
prophylaxis • Optimal fluid therapy Follow-up
• Hypotermia
prophylaxis
Preoperative ERAS components

Patient information
Health/medical optimisation
Nutrition
Fasting time
Carbohidrate drinking
Pre-anesthestic medication
Anti-thrombotic prophylaxis

U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

Preoperative ERAS components

Patient information
Health/medical optimisation
Nutrition
Fasting time
Carbohidrate drinking
Pre-anesthestic medication
Anti-thrombotic prophylaxis
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
Patient information

Preadmission education and counselling

Decrease fear and anxiety

 Improve Enhance
 wound healing Postoperative
 perioperative feeding Recovery
 postoperative mobilisation and Discharge
 pain control
Reduce the prevalence of complications

U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

Preoperative ERAS components

Patient information
Health/medical optimisation
Nutrition
Fasting time
Carbohidrate drinking
Pre-anesthestic medication
Anti-thrombotic prophylaxis
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
 Prehabilitation

Preoperative improvement of physiological function

Increasing exercise preoperatively

 WALK
 Training programs
 Prehab
Preoperative improvement of physiological function

Increasing exercise preoperatively

 WALK
 Increasing distance


Increasing duration
Increasing frequency Easier to implement
Psychological preparation
Motivation – adherence to exercise
Less efficient
Preoperative ERAS components

Patient information
Health/medical optimisation
Nutrition
Fasting time
Carbohidrate drinking
Pre-anesthestic medication
Anti-thrombotic prophylaxis
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
Perioperative consequences of malnutrition

Norman, Clinical Nutrition, 2008,27, 5/15

ESPEN RECOMMENDATIONS

Preoperative
All malnourished patients

All cancer patients

Scheduled for upper gastro-intestinal surgery
No matter the nutritional status

Preoperative enteral (immuno)nutrition

for 10–14 days
RECOMMENDATION GRADE A
Preoperative ERAS components

Patient information
Health/medical optimisation
Nutrition
Fasting time
Carbohidrate drinking
Pre-anesthestic medication
Anti-thrombotic prophylaxis
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
Preoperative fasting

 Standard practice – fasting from midnight

 reduce the volume and acidity of stomach contents
 decrease the risk of pulmonary aspiration
But … Thirst, headaches, hunger

Cochrane review of 22 RCTs

fasting from midnight
 no reduction in gastric content
 no rise in pH of gastric fluid
clear fluids until 2h before anesthesia

Brady M, et al. Cochrane Database Syst Rev 2003;(4). CD004423.

Eur J Anaesthesiology 2011;28:556-569
What are the effects
of the preoperative fasting ?
Surgical stress

Insulin resistance
Insulin sensitivity falls
with the magnitude of surgery
More
100 insulin
resistance
Percentage (%)

50

Thorell A et al, Curr Opin Clin Nutr Metab Care 1999; 2: 69

Insulin resistance cause complications

• Elective cardiac surgery, n= 273

• Diabetics and non diabetics

Complications increase with insulin resistance:

50% reduction in insulin sensitivity:
• 5-6 fold increase risk of complications
• 10 fold risk for infections

Sato et al, JCEM 2010, 95; 4338-44

Carbohydrate treatment

 12.5% carbohydrate drink

– 400 ml 2h before anesthesia
+ 800 ml evening before

 Induce insulin release

Setting before surgery

Fasted CHO fed

Hyperglycemia - +
Insulin sensitivity - + 50%
Glucose production + ---
Peripheral glucose uptake - +++

Ljungqvist et al, Clin Nutr 2001 , Svanfeldt et al Clin Nutr 2005

Carbohydrate treatment

 20% glucose iv

 12.5% carbohydrate drink

– 400 ml 2h before anesthesia
+ 800 ml evening before

 Safety ???
 Carbohydrate treatment

Gastric emptying is complete in 90 min for CHO / water

120 CHO, n=6
*
100 * Water, n=6
Isotope activity in
the stomach (%)

80 *
60
*
40
*
20
0
0 30 60 90 120
Minutes after intake

Nygren et al, Ann Surg, 1995

 Preop CHO reduces
postoperative insulin resistance

20
CHO *P < 0.05
Per cent change from preop

10 Control
0
-10
-20
-30
-40
* * * * More
-50 resistance
-60
Cholecystectomy Colorectal Arthroplasty Arthroplasty

Nygren et al: Curr Opin Clin Nutr Metab Care 2001

All recent Guidelines recommend
oral carbohydrate loading

Germany 2003: Major surgery

Anaesthesist. 2003 Nov;52(11):1039-45.

Scandinavia 2005: Major surgery

Acta Anaesthesiol Scand. 2005 Sep;49(8):1041-7

ESPEN 2005: Major surgery

Clin Nutr. 2006 Apr;25(2):224-44

ESPEN 2009: Major surgery

Clin Nutr. 2009 May 20

United Kingdom 2009: Elective surgery

J Intensive Care Society. 2009;10(1):13-5

European Soc Anesthesiology 2011: Elective surgery

Eur J Anaesthesiology. 2011;28:556-569
Preoperative ERAS components

Patient information
Health/medical optimisation
Nutrition
Fasting time
Carbohidrate drinking
Pre-anesthestic medication
Anti-thrombotic prophylaxis
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
Pre-anesthetic medication

Education Avoid starvation CHO loading

No sedative medication
before surgery

U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

Preoperative ERAS components

Patient information
Health/medical optimisation
Nutrition
Fasting time
Carbohidrate drinking
Pre-anesthestic medication
Anti-thrombotic prophylaxis
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
Anti – thrombotic prophylaxis

Risk in colorectal surgical patients

DVT – 30% PE – 1%

Mechanical Pharmacological

Compression Intermitent LMWH

stockings in pneumatic for 28 days
all patients compression in cancer patients

U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

Intraoperative ERAS components

 Antimicrobial prophylaxis
 Anesthesia protocol
 Multimodal analgesia
PONV
 Fluid management
 Hypotermia prophylaxis
Intraoperative ERAS components

 Antimicrobial prophylaxis
 Anesthesia protocol
 Multimodal analgesia
PONV
 Fluid management
 Hypotermia prophylaxis
Antimicrobial prophylaxis

 Imperative to reduce the risk of surgical infections

 Time
 30-60 min before the incision
 repeated doses
 during prolonged procedure (≥3h)
 Massive blood loss/fluid loading
 Route
 intravenous
 Spectrum
 Suspected germs (aerobic ± anaerobic bacteria)
Intraoperative ERAS components

 Antimicrobial prophylaxis
 Anesthesia protocol
 Multimodal analgesia
PONV
 Fluid management
 Hypotermia prophylaxis
 Anesthetic protocol

Target – rapid awake of the patient

Anesthesia technique
 Balanced anesthesia
 TIVA
 Short acting agents
 Hypnosis – propofol, sevoflurane, desflurane
 Analgesia – sufentanil, remifentanil
 Myorelaxant – cisatracurium
Intraoperative Monitoring

BIS

Hypnosis

Algiscan TOF

Muscle
Analgesia
relaxation
ERAS
Oesophageal
Glucometer doppler

Cardiac
Glucose
output
Intraoperative ERAS components

 Antimicrobial prophylaxis
 Anesthesia protocol
 Multimodal analgesia
PONV
 Fluid management
 Hypotermia prophylaxis
Multimodal analgesia

Epidural analgesia
iv analgesia
Wound catheters/infiltration
Peripheral blocks
Intraoperative ERAS components

 Antimicrobial prophylaxis
 Anesthesia protocol
 Multimodal analgesia
PONV
 Fluid management
 Hypotermia prophylaxis
PONV

 Risk factors
 Patient: female, non smokers, motion sickness
 Anestetic: volatile agents, iv opioids, nitrous oxide
 Surgical: major abdominal surgery
 PONV scoring systems
 Multimodal approach
 Pharmachological
 Non-pharmachological techniques: TIVA, minimal
fasting, CHO loading, adequate hydration, epidural,
NSAIDS
Intraoperative ERAS components

 Antimicrobial prophylaxis
 Anesthesia protocol
 Multimodal analgesia
PONV
 Fluid management
 Hypotermia prophylaxis
Perioperative fluid management

DO2 = CO (SV x HR) x CaO2 x 10

Bundgaard-Nielsen,et al. Acta Anaesth Scand 2009, 53: 843–851

Goal directed intra-operative fluid therapy

Noblett et al. BJS 2009

Meta analysis based on amount of fluid given

<1.75 liters/24h >2.75 liters/24h

Varadhan K, Proc Nutr Soc, 2010
Fluids – recent meta‐analysis

Rahbari NN, BJS 2009: 96: 331

Intraoperative ERAS components

 Antimicrobial prophylaxis
 Anesthesia protocol
 Multimodal analgesia
PONV
 Fluid management
 Hypotermia prophylaxis
Hypothermia prophylaxis
 Hypothermia – central temperature < 36 C
 Risk factor for
wound infections, prolonged cicatrisation
cardiac events
shivering – increase O2 consumption
bleeding
coagulation disorders
trombocites dysfunction
postoperative ileus
increase pain
prolonge emergence time
Hypothermia prophylaxis

Hypothermia – central temperature < 36 C

Methods
warming devices
(forced air warming blankets)
warmed iv fluids
warm gases in laparoscopic surgery
Postoperative ERAS components

Postoperative analgesia
Fluid management
Postoperative glycaemic control
Postoperative nutrition
Early mobilisation
Postoperative ERAS components

Postoperative analgesia
Fluid management
Postoperative glycaemic control
Postoperative nutrition
Early mobilisation
Postoperative analgesia

• Optimal analgesic regimen

– Good pain relief
– Reduction of cardiovascular, cognitive, endocrino
– metabolic complications in at risk patients
– Decrease the risk of chronic pain
– Early mobilisation
– Early return of gut function and feeding
Epidural analgesia vs opiates GI function

• EDA results in less GI paralysis (vs iv opiates)

Jorgensen Cochr Database Syst Rev 2004

Postoperative ERAS components

Postoperative analgesia
Fluid management
Postoperative glycaemic control
Postoperative nutrition
Early mobilisation
 Varadhan K, Proc Nutr Soc, 2010

59% reduced risk for complications

3.4 days reduction in hospital stay

Postoperative ERAS components

Postoperative analgesia
Fluid management
Postoperative glycaemic control
Postoperative nutrition
Early mobilisation
Hyperglycemia in surgical stress

 Insulin resistance is the key

Traditional belief

 Hyperglycemia in the acutely stressed patient is

”not dangerous”
 Glucose levels treated > 200 mg/dl
Several stress-reducing interventions in ERAS
attenuate insulin resistance as single interventions:
• preoperative oral carbohydrate treatment
• epidural blockade
• minimally invasive surgery

If interventions are combined in ERAS protocol,

hyperglycaemia can be avoided
even during full enteral feeding starting immediately after major
colorectal surgery.
Postoperative ERAS components

Postoperative analgesia
Fluid management
Postoperative glycaemic control
Postoperative nutrition
Early mobilisation
Postoperative nutrition

Fluids immediately after recovery from anesthesia

Normal hospital food on day 1

Food intake

1600

1200
kcal / 24h

800

400

0
1 2 3 4
Postop days

 traditional care Nygren Clin Nutr 2003

 enhanced-recovery protocol
Postoperative early enteral nutrition

Lewis et al BMJ 2001;323(7316):773-6

Postoperative ERAS components

Postoperative analgesia
Fluid management
Postoperative glycaemic control
Postoperative nutrition
Early mobilisation
Early mobilisation
EFFECTS
•Early return of bowel function
• Improved digestive tolerance
• Enhanced anabolism
• Decreased risk of venous thromboembolism
• Deacreased risk of pulmonary complications
• Enhanced recovery !!!

CONDITIONS
• Good analgesia
• No ventilatory support
• No postoperative somnolence
• Psycological support
 Outline

 Anesthetist approach
 Surgeon approach
 Protocolization
SURGEONS!!

TRADITION EVIDENCE
BASED
MEDICINE
BOWEL PREPARATION

• PRO
– Avoids massive contamination !?!
– Minor inconvenience to the patient !?!
– Looks better inside !?!

• CON
– Preoperative dehydration !!!
– Modification of enteral flora !!!
– Delayed gut motility !!!
 Arch Surg. 2004 Dec;139(12):1359-64; discussion 1365.
Mechanical bowel preparation for elective colorectal surgery: a
meta-analysis.
Bucher P, Mermillod B, Gervaz P, Morel P.

CONCLUSIONS: 7 trialuri 1300 pt

…There is no evidence to support the use of MBP
in patients undergoing elective colorectal surgery.

Available data tend to suggest that MBP could be harmful

with respect to the incidence of anastomotic leak and
does not reduce the incidence of septic complications.
 NO routine naso-gastric tube

• 28 multicenter trials >4000 pts

– Decreased duration of postoperative ileus

– Decreased risk of postoperative pulmonary complications
– Increased patient QOL
– No increase in anastomotic leak

Nelson, R. at all Systematic review of prophylactic nasogastric

decompression after abdominal operations.
Br. J. Surg., 2005, 92, 673–680.
 No drains

• Rationale of drains:
“When in doubt, drain”
Lawson Tait, english surgeon

“The drain= the surgeon eye in the patients abdomen”

• A surgical tradition
• Difficult to be abandoned
• For how long? 24h / 48h / 7days ???
• In majority of cases – serous drained fluid
(physiological reabsorption)
No drains

• RCTs:
– Unreliable indication of anastomotic leak
– Underestimates the significance of anastomotic leak
– Underestimates the postoperative bleeding
– Does not influence the rate of anastomotic leak
– Increases the contamination risk
– Prolongs the duration of postoperative ileus
– Prolongs the hospital lenght of stay

Petrowsky, H. at all: Evidence-based value of prophylactic drainage in

gastrointestinal surgery: A systematic review and meta-analyses.
Ann. Surg., 2004, 240, 1074–1085.
 Outline

 Anesthetist approach
 Surgeon approach
 Protocolization
Preoperative Preoperative Preoperative
Properative
Fasting
Carbohydrates
optimisation nutrition prophylaxys
Treatment

Fluid Preventing
Analgesia management PONV
hypotermia

Postoperative Early
Fluid
Analgesia
management nutrition mobilisation
Results?

Randomised trials
Meta analysis
ERAS - clinical outcome

 Review of 6 RCTs (n=452)

Mortality

K K. Varadhan et al. Clin Nutr, 2010: 29 ;434–440

ERAS - clinical outcome

 Review of 6 RCTs (n=452)

Length of stay

Shorter length of stay by 2.5 days

K K. Varadhan et al. Clin Nutr, 2010 : 29 ;434–440

 ERAS - clinical outcome
 Review of 6 RCTs (n=452)
Complications

Reduce complications by 50%

K K. Varadhan et al. Clin Nutr, 2010: 29 ;434–440

“Fast-track” rehabilitation after colonic surgery in elderly patients—is it feasible?
International Journal of Colorectal Disease Volume 22, Number 12 / December, 2007
M. Scharfenberg1, W. Raue1, T. Junghans1 and W. Schwenk1

Conclusion Using the “fast-track” rehabilitation programme on elderly patient is not only
feasible but may also lower the number of general complications and the duration of the
hospital stay.

Ciaran O’Hare Ciaran O’Hare

Implementation of the ERAS protocol

 select a target
 invite participation to create a team
 explain what you are trying to achieve
 select an “expert group”
 create change concept and priorities
 implement strategy
 regular review to measure and evaluate change
 review strategy

Implementation in Practice (C.H.C. Dejong, Netherlands)

http://www.jspen.jp/doc6/sec7.html
 Anesth Analg 2007;104:1380-1396
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000263034.96885.e1

AMBULATORY ANESTHESIA

The Role of the Anesthesiologist in Fast-Track Surgery:

From Multimodal Analgesia to Perioperative Medical Care
Paul F. White, PhD, MD*, Henrik Kehlet, MD, PhD , and the Fast-Track Surgery Study Group

CONCLUSION: The decisions of the anesthesiologist as a key perioperative

physician are of critical importance to the surgical care team in developing a
successful fast-track surgery program.
“Surgery and peri-operative care remains heavily based in tradition”

This is the biggest challenge

facing the wide implementation and acceptance of ERAS programs.