aagbi enhanced recovery seminar april 2010

Anaesthesia, Goal Directed Therapy andEnhanced Recovery for

Colorectal SurgeryThursday 22 April 2010

Organisers: Dr Mike Scott & Dr William Fawcett, Guildford

Programme:

Introduction & overview – A national perspectiveAnn 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

AAGBI Meeting 22nd April 2010 Overview of Enhanced Recovery in Colorectal Surgery Dr Mike Scott Royal Surrey County NHS Foundation Trust, Guildford Enhanced Recovery (ER) is now established as a modality that can be used to reduce the length of stay and morbidity after major surgery. It was established by Kehlet and colleagues as part of the ERAS (Enhanced Recovery After Surgery) group in Scandinavia and is being adopted and implemented across the UK by the Department of Health. It is based around 17 points of care to minimise intervention and return the patients back to independence and mobility with increasing oral diet. Some UK centres , including ours, have used it for the last 4 years with increasing success. Laparoscopic Colorectal surgery is ideally suited for ER as patients can eat and drink after surgery and the SIRS response is also a lot more limited compared to upper GI Surgery. We have simplified the approach to Enhanced Recovery by delivering most of the ER components by protocol but taking out the fluid/oxygen delivery and analgesic components. We feel these are the most important individual components to achieve a successful outcome apart from the surgery itself and are delivered by the anaesthetist.

Simplified Enhanced Recovery in Laparoscopic Colorectal Surgery– Trimodal Model

Enhanced Recovery Protocol

Individualised

Fluid TherapyEffective

Analgesia

Early Mobility Early Gut

Function

Modulation of stress response

Scott Fawcett Levy Rockall


Early MobilityEarly Gut Function Modulation of

stress response

Decreased

Complications Healing

Decreased Length of

Stay


These components combined with early mobility lead to early feeding and gut function. This in turn helps to modulate the stress response and promotes healing. Reduced complications and secondary infection lead to a decreased length of stay.

Analgesia There has been much controversy over the optimal analgesic modality in laparoscopic colorectal surgery. Most groups accepted the concept that Epidural Analgesia which was a proven benefit in open surgery would be transferrable to laparoscopic surgery. We have not found this so. Short duration of inpatient stay has been successful by groups using morphine. Our carefully practised use of spinal analgesia combined with general anaesthesia has lead to a reproducible 23 hour stay. Our experience with epidurals in an RCT with Oesophageal Doppler guided fluids has shown patients with epidurals are more immobile, receive more fluid and have a longer time to bowel function and hospital discharge. Fluids and Oxygen Delivery Laparoscopic surgery is not without its own problems. Complex surgery, length of surgery and bleeding can all lead to increased length of stay. We believe individualised fluid therapy using Oesophageal Doppler (OD) is one of the most important strategies to be adopted by anaesthetist as well using modern anaesthetic techniques. Our haemodynamic studies have shown a reduction in oxygen delivery during laparoscopic surgery due to increased aortic afterload which we believe is detrimental in certain patient groups such as the elderly and those with co morbidity. This can be exaggerated further by the steep head down position common in a lot of laparoscopic colorectal procedures. Unless OD is used in these groups and oxygen delivery optimised during and at the end of the procedure some of the benefits of having minimally invasive surgery are negated by an oxygen deficit and splanchnic hypoperfusion.

Outcome Short inpatients stays utilising ER and minimally invasive surgery has been shown to be safe with good patient satisfaction. With patient selection and optimal care 23 hour stay is achievable. Two to four days is more usual for our patients, particularly those who are elderly or with co‐morbidities. Our patient follow up outcome has demonstrated an improved 5 year mortality when compared to national figures by upto 30% for an equivalent Duke’s stage cancer. It is unclear exactly why there is this benefit but If this improvement in outcome is substantiated then perioperative care using enhanced recovery and minimally enhanced surgery should be now viewed as an important treatment strategy in cancer. Key References for Fast track Colorectal Surgery1‐7 1. Delaney CP. Outcome of discharge within 24 to 72 hours after laparoscopic colorectal surgery. Dis Colon Rectum 2008;51(2): 181‐185. 2. Kehlet H. Randomized controlled trial to examine the influence of thoracic epidural analgesia on postoperative ileus after laparoscopic sigmoid resection. Br J Surg 2000;87(3): 379. 3. Kehlet H. Postoperative ileus‐‐an update on preventive techniques. Nat Clin Pract Gastroenterol Hepatol 2008;5(10): 552‐558. 4. Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, von Meyenfeldt MF, Fearon KC, Revhaug A, Norderval S, Ljungqvist O, Lobo DN, Dejong CH. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009;144(10): 961‐969. 5. Levy BF, Scott MJ, Fawcett WJ, Rockall TA. 23‐hour‐stay laparoscopic colectomy. Dis Colon Rectum 2009;52(7): 1239‐1243. 6. 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. 7. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Fleming SC. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 2005;95(5): 634‐642. 8. http://www.18weeks.nhs.uk/content.aspx?path=/achieve‐and‐sustain/Transforming‐and‐improving/enhanced‐recovery/ 9. Levy B, Dowson H, Scott M, Stoneham J, Fawcett W, Zuleika M, Rockall T. Trans‐oesopageal Doppler assessment of the haemodynamic changes occurring during laparoscopic colorectal surgery. BJS 2008; 95(S3):57

1

Overview of Enhanced Recovery In Colorectal Surgery

Dr Mike Scott FRCP FRCA Consultant in Anaesthesia and Intensive Care Medicine

Royal Surrey County NHS Foundation Trust and St Luke’s Cancer Centre

Guildford UK

Enhanced Recovery Partnership Programme

Cancer Action Team

http://www.18weeks.nhs.uk/

Name Job Title Organisation

Mrs Teresa Moss Director National Cancer Action Team

Professor Roger Motson Consultant Colorectal Surgeon Colchester General Hospital/ ICENI

Mr Tan Arulampalan Consultant Colorectal Surgeon Colchester General Hospital/ ICENI

Sr Jane Hendricks Theatre practitioner/ ER co-ordinator

Colchester General Hospital/ ICENI

Professor Tim Rockall Consultant Colorectal Surgeon Royal Surrey County Guildford / MATTU,

Dr Mike Scott Consultant Anaesthetist Royal Surrey County Guildford / MATTU,

Dr Bill Fawcett Consultant Anaesthetist Royal Surrey County Guildford / MATTU,

Mr Alan Horgan Consultant Colorectal Surgeon Freemantle Hospital, Newcastle

Mr Charles Maxwell-Armstrong

Consultant Colorectal Surgeon Queen’s Medical Centre, Nottingham

Mr Austin Acheson Consultant Colorectal Surgeon Queen’s Medical Centre, Nottingham

Mr Robin Kennedy Consultant Colorectal Surgeon St Mark’s Hospital, North West London Hospitals NHS Trust

Ms Astra Tertullien ERP Programme Co-ordinator St Mark’s Hospital, North West London Hospitals NHS Trust

Mr Omar Faiz St Mark’s Hospital, North West London Hospitals NHS Trust

Mr Mark Coleman Lap. Colorectal NTP LeadConsultant Colorectal Surgeon

Plymouth Hospitals NHS Trust

Mr Nader Francis Consultant Colorectal Surgeon Yeovil District NHS Foundation Trust

Mr Jonathan Ockrim Consultant Colorectal Surgeon Yeovil District NHS Foundation Trust

Dr Roger Kipling Consultant Anaesthetist Yeovil District NHS Foundation Trust

Sr Louise Evans Senior Ward Sister Yeovil District NHS Foundation Trust

Dr Fiona Carter Course Development Manager Yeovil District NHS Foundation Trust

MATTU Guildford, University of SurreyNational and European Laparoscopic Training Centre

Prof Tim Rockall, Mr Iain Jourdain, Research Fellows: Bruce Levy , Andy DayDr Bill Fawcett, Dr Mike Scott, Dr John Stoneham

National Directive

• Laparoscopic Colorectal Procedures where possibleE h d R• Enhanced Recovery

• Training for Surgeons and ER Team• (Retraining)

2

Example of enhanced recovery elements

Referral fromPrimary Care

Pre-Operative

• Planned mobilisation• Rapid hydration & nourishment

• Appropriate IV therapy• No wound drains• No NG (bowel surgery)• Catheters removed early

• Regular oral analgesia

• Admission on day• Optimised Fluid

Hydration• CHO Loading• Reduced starvation• No / reduced oral

bowel preparation ( bowel surgery)

• Optimising pre operative haemoglobin levels

• Managing pre existing co morbidities e.g. diabetes

7

Admission

Intra-Operative

Post-Operative

FollowUp

• 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

• Regular oral analgesia• Paracetamol and NSAIDS

• Avoidance of systemic opiate-based analgesia where possible or administered topically

• DX when criteria met• Therapy support (stoma, physio)

• 24hr telephone follow up

Why is Colorectal surgery well suited to an ER program?

• Colorectal surgical procedures are well subscribed and reproducible due to modern technology (staple guns etc)

• SIRS response limited unlike complexSIRS response limited, unlike complex upper GI

• Provided no complications then patients recover quickly – (HOW QUICKLY?)

Levy BF, Scott MJ, Fawcett WJ, Rockall T,

23-hour-stay laparoscopic colectomy.[Controlled Clinical Trial Journal Article]

23 Hour Stay Laparoscopic Colectomy

[Controlled Clinical Trial, Journal Article]

Dis Colon Rectum 2009 Jul; 52(7):1239-43.

Enhanced Recovery

• Denmark – Kehlet’s Group• Open surgery• Produced backbone of work around which

h f l t d ‘ h d ’has formulated ‘enhanced recovery’• 20 points• Reduced length of stay dramatically

Enhanced Recovery Model 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• Modern anaesthesia• Fluid management• Analgesia – Thoracic Epidural• Early oral intake• Early mobilisation

3

Enhanced Recovery

• Pre-op education• Avoidance of bowel preparation• Pre-operative carbohydrate drink• Avoidance of pre-op sedatives• Thoracic epidural started before

• 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 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

y g y2

• 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

• 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 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

y g y2

• 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)

Day by Day Summary

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 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 f d d d i k• Oral food and drink

• Oral analgesia

4

Challenging established concepts

Groups around the UK are challenging the established concepts in open surgery of:

1) Pain relief using alternatives than epidural analgesia:SpinalSpinalPain busterTAP Block

2) How long to keep patients in hospital3) 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 Model Simplified Enhanced Recovery in Laparoscopic

Colorectal Surgery– Trimodal Model

Enhanced Recovery Protocol

Individualised

Fluid TherapyEffective

Analgesia


Early Mobility Early Gut

Function



Early MobilityEarly Gut Function Modulation of

stress response


Decreased


Decreased Length of

Stay

Analgesia: Open v Laparoscopic

• Epidural has been recognised as the ‘gold standard’ for open surgery

• Usually run for 48-72 hours• Analgesic adjuncts necessaryAnalgesic adjuncts necessary

There has been as assumption in the medical world that epidurals will give the same advantages in patients undergoing Laparoscopic surgery

5

RCT CompletedLevy BF, Scott MJ, Fawcett WJ, Rockall T

• 3 groups 102 patients• Epidural v spinal v morphine• All received Oesophageal Doppler guided fluids

within Enhanced recovery protocolwithin Enhanced recovery protocolEndpoints• Fluids & vasoconstrictors used, weight gain• Respiratory function and mobility• LOS, morbidity, mortality• Patient satisfaction, QWALYs

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

Summary of Work • Spinal group best in recovery• 10% of spinal group needed morphine in

recovery – morphine ‘rescue’ increases with length of operationS i l d hi i il t 24 h• Spinal and morphine group similar at 24 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 SurgeryMaximum 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

6

48 Hours Post-OpWhich is the optimal stress

response?

Epidural group in hospital Spinal group at home

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):1239-43.

Inclusion criteria• 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 techniqueStandard surgical technique• GA plus spinal anaesthesia

Anaesthetic Technique

• Sitting awake spinal 2.5mls Hyperbaric Bupivicaine0.5% with Diamorphine 0.25%

• Induction: Propofol / Alfentanil / Rocuronium• (Central venous line used to measure post –op

ScvO2)ScvO2)• Fluid optimisation using oesophageal Doppler prior to

insufflation• IPPV O2 / Air / Sevoflurane• (Remifentanil Infusion) / Phenypherine as needed

7

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• 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 downpatient takes solid foods, IVI down

• all 3 criteria reached• patient willing to go home / has support at

home

Perioperative care Pathways

3 Groups of Patients:No co morbidities

Major co morbidities

Elderly (with or without co-morbidities)

ERAS results by age

What perioperative factors make patients deviate off care pathway and increase Length of Stay?

• Length of time of surgery important:

1. surgeons experience2. difficulty of operation / mobilisation of bowel3. teaching

• Bleeding• Failure of Analgesia• Early post-operative vomiting

In Patient Care Pathways

8

ER - What’s it all about?

• Reduced length of stay• Reduced morbidity

R d d i ti t lit• Reduced perioperative mortality• Reduced perioperative costs

What’s it really all about: survival

50

60

70

0

10

20

30

40

80-89 70-79 60-69 50-59 40-49 15-39

ColonColumn2RectumColumn3

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 i f i d t t ti t• Early review of our series demonstrates patients 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 Recovery2. Individualised fluid therapy using Oesophageal

D l d li iti t ti IV fl idDoppler and limiting post operative IV fluids3. 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-OpWhich is the optimal stress

response?

Epidural group in hospital Spinal group at home

“Perioperative fluid administration for abdominal surgery : liberal or restrictive regimen ?”. 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 – [email protected] 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 Brandstrup’s 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 intra-operative 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: 1099–103. 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: 99–104 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): 637–46 (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

1

Analgesia for open and laparoscopic surgerylaparoscopic surgeryDr William Fawcett FRCA FFPMRCA

Consultant in Anaesthesia and Intensive Care Medicine Royal Surrey County Hospital, Guildford, Surrey, UK

22/4/2010

Enhanced Recovery Partnership Programme

Cancer Action Team

http://www.18weeks.nhs.uk/

Colorectal Surgery Model

Analgesia for open surgery

Henrik Kehlet, MD, PhDSurgeon and Professor of Perioperative Therapy at the Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Denmark.

Open Surgery

Thoracic epidural anaesthesia classic approach

Well studied over last 20 yearsy

Many published benefits

Part of multimodal approach to postoperativerecovery

2

Benefits of neuroaxial block

Overall reduction in:

Mortality by 30%Deep vein thrombosis by 44%p yPulmonary embolism by 55%Transfusion requirements by 50%Pneumonia by 39%Respiratory depression by 59%

(P < 0.001)

Also reductions in myocardial infarction and renal failure

Rodgers A et al. BMJ 2000;321:1493

Epidurals and colorectal surgery

Reduction in reduce the classic pituitary, adrenocortical, and sympathetic responses to surgeryg y

Does not modify inflammatory or immunological responses

Opioid sparing, quicker return to GI function

Balanced or Multimodal analgesiaKehlet H et al Anesthesia and Analgesia 1993;77:1048-56

Variety of approaches to reduce opioid consumption including:

Local anaesthetics including wound infusions ParacetamolNSAIDsOthers including gabapentin, clonidine and ketamine, lignocaine

Problems with analgesia

NSAIDs: renal, bleeding, perforation, anastomotic leakage

Paracetamol

Opioids: sedation, constipation, PONV

Local anaesthetics

How good are epidurals?

EpiduralsWell described problems include:

– Hypotension– Poor mobility

Neurological damage– Neurological damage– Up to 50% don’t work adequately

MASTER trialRigg JRA et al. Lancet 2002;359:1276-82

“Epidural analgesia: first do no harm”Low J et al Anaesthesia 2008;63:1-3

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, kidneysOther 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

Pain teamsExcellent pain control ≠ reduction in

morbidity, mortality and hospital stay

Analgesia for laparoscopic surgeryapa os op su g y

Laparoscopic surgery

How much is transferable from open surgery?

Little data for optimum analgesictechnique in laparoscopic colorectal surgery

Laparoscopic vs open

Differences– Intraoperative cardiopulmonary stresses

are greater and effects of block magnifiedg 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

4

Laparoscopic surgery

Simple analgesics often all that isrequired at 24 hours:

• Paracetamol• Paracetamol• NSAIDs• Tramadol/codeine

Intense analgesia for first 12-24 hours only

Laparoscopic surgery –first 24 hours

Treatment options:

–Epidural–Spinal –iv morphine (PCA)

Analgesic regime

Epidural

– Classic approach to enhanced recovery– Avoidance of opioidsp– Parasympathetic tone– ? Relevance of DVT/PE, blood loss, “stress response”,

respiratory functionBUT:

– Risk of exaggerated CVS changes during positioning– Risk of high block– ?Poor mobilisation

Analgesic regime

Spinal

– Avoidance of systemic opioids– Parasympathetic toneParasympathetic tone– Mobilisation improved by single shot– Higher success rate and lower complication

compared to epiduralsBUT

– 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 gfunction 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

5


Epidurals (contd)

– “ better postoperative pain relief and– .. better postoperative pain relief, and faster recovery of gastrointestinal function”

– Zingg U et al. Surgical Endoscopy 2009;23:276-282

– No study has shown reduction in hospital stay


Spinals– Very little evidence– We used spinals successfully for first 23-We used spinals successfully for first 23

hourstay laparoscopic colectomy paper. Levy BF. Scott MJP. Fawcett WJ. Rockall TA.

Diseases of the Colon & Rectum. 2009;52:1239-43

– 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 down2 5mls 0 5% diamorphine 2 5mg– 2.5mls 0.5%, diamorphine 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):57Levy 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

Spinal 48%

Epidural 89%

PCA 35%

PCA vs epidural p=0.014Spinal vs epidural p=0.049

Respiratory changes

Spinal Epidural PCAPreop Postop Preop Postop Preop Postop

FEV1(l)

2.14 1.65 2.15 1.55 2.41 1.68

FVC(l)

2.70 2.01 3.03 1.90 2.95 1.94

PEFR(l/min)

344 245 352 225 419 246

6

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 consumptionAmount of morphine (mgs) for spinal patients

Amount of morphine (mgs) for PCA patients

Mean 6.0 59.9

Std deviation 10.2 33.1

Range 45 146

Length of stay

Spinal Epidural PCA

Length of stay (days)

4.5* 7.2 4.2

* p=0.007 p<0.001

What is the future?

Analgesia is a major component in ERPsGood analgesia alone is not the endpointMultimodal analgesia vitalMultimodal analgesia vitalRegular review by pain team and other

staffA number of controversial areas still exist

Newer Areas

Lidocaine infusions

• Reduction in analgesic requirements, ileus and PONV

• Opioid consumption reduced by 2/3• Reduced hospital stayBUT• May be less relevant in small incision vs

classical open surgeryMarrett E et al BJS 2008;95:1331-1338

7

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• Morphine consumption halved• Side effects: sedation, delusions, nightmares,

psychiatric disorders not manifest at these doses.Zakine J et al. Anesth Analg 2008;106:1856–61

BUT• Dose and duration debated

TAP blocks

• Transversus abdominus plane block• Many use ultrasound guidance• Convincing opioid sparing effect for• Convincing opioid sparing effect for

both open surgery (75%) and laparoscopic surgery (50%)

• Very promisingMcDonnell JG et al. Anesth Analg 2007;104:193-197

El -Dawlatly AA et al. BJA 2009;102:763-7

Local Anaesthetic into Wound

• Continuous infusion via elastomeric device

• Used in many types of surgeryUsed in many types of surgery• Promising early reduction in opioid

consumption in open bowel surgery• Little evidence so far in laparoscopic

surgeryPolglase AL et al.

Diseases of the Colon & Rectum. 2007;50:2158-2167

“Stress response”

Contentious areas:

“Analgesia is all that matters”


Systemic change following surgery and trauma:• Endocrine (pituitary and adrenals)• Metabolic (catabolism, hyperglycaemia)• Inflammatory (cytokines)Inflammatory (cytokines)• Immunosuppression

Magnified by starvation, infection and hypovolaemia

Disappointingly, modification unproven benefit


– Neuroaxial blocks effective at reducing endocrine & metabolic changes especially for pelvic surgery

– Some claim this is key factor for ERPHowever this requires block with LA prior to– However this requires block with LA, prior to 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;550:22-8Fawcett WJ et al. Anaesthesia 1997;52:294-299

8

“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 RecoveryEnhanced Recovery

Fluid Therapy Analgesia

Early Mobility Gut Function


Enhanced RecoveryEarly Mobility Gut Function Modulation of

stress response

Reduced


Reduced Length of

Stay

Pitfalls in analgesia - epidurals

Fluid control– Even with GDFT may result in fluid

overload

Mobilisation

Early removal of catheters

Pitfalls in analgesia - PCA

Nausea and vomiting

IleusIleus

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: 665–673

‘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: 1921–28

9

Perspective

‘It is time to "roll up our sleeves and get back to work" doing high-quality clinical research rather than simply reanalyzing previously

bli h d t di ’published studies’White PF, Kehlet H. Anesth Analg 2007;104:487-489

‘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

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

Summary

We can no longer practice analgesia in isolation

Constantly re-evaluate our techniquey q

Extrapolation of previous work maybe flawed

Further research required

4/22/2010

1

Focus on laparoscopic Focus on laparoscopic colorectal procedures: colorectal procedures:

Improving the periImproving the peri--operative care pathwayoperative care pathway

Dr. Patrick MorganDr. Patrick Morgan2222ndnd April 2010April 2010

IntroductionIntroductionPrePre--assessmentassessmentRisk stratificationRisk stratificationPrePre--operative managementoperative managementIndividualised approachIndividualised approachPostPost--operative courseoperative course

MultiMulti--disciplinary approachdisciplinary approachSurgeon Surgeon PrePre--assessment team assessment team Colorectal nursesColorectal nursesPhysiotherapistsPhysiotherapistsOccupational therapists Occupational therapists AnaesthetistsAnaesthetistsPain management teamPain management teamNutritional teamNutritional teamWard nursing staffWard nursing staffMedical staffMedical staffSocial workersSocial workers

Evidence basedEvidence based

ning/reorganisation and procedure specPreoperativemation for patientsPrehabilitationohol and smoking

ti

Intraoperative• Stress reduction

• Prophylactic antibiotics• Perioperative oxygen therapy

Postoperative• Effective pain relie

prophylaxis for nausevomiting

cessationutritional support eoperative fluid &bohydrate intakeNursing careLess use of

• Regional anaesthesia• Minimally invasive operations

• Normothermia• Choice of incision

• Intraoperative fluids

L f D i d

• Early mobilisatio• Early oral feedingdietary supplement

L f T b d

PrePre--operativeoperativeInformation for patientsInformation for patientsPrehabilitationPrehabilitationAlcohol and smoking cessationAlcohol and smoking cessationNutritional support (for malnourished patients)Nutritional support (for malnourished patients)Preoperative fluid & carbohydrate intakePreoperative fluid & carbohydrate intakeNursing careNursing careLess use of Mechanical bowel preparationLess use of Mechanical bowel preparation

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InformationInformationEducation for patient and relativesEducation for patient and relativesEncourages motivationEncourages motivationPrePre--hospital stoma educationhospital stoma education

PrePre--operative stoma educationoperative stoma education42 patients42 patientsReduced hospital LOSReduced hospital LOSReduced time to stoma proficiencyReduced time to stoma proficiencyReduced community stoma interventionsReduced community stoma interventionsCost saving of £1119 per patientCost saving of £1119 per patient

Preoperative Intensive, CommunityPreoperative Intensive, Community--Based Based vs. vs. Traditional Stoma Traditional Stoma Education: A Randomized, Controlled Trial. Chaudhri et al. Dis Col Education: A Randomized, Controlled Trial. Chaudhri et al. Dis Col Rect 2005Rect 2005

PrehabilitationPrehabilitation

Reduced LOS in spinal surgical patientsReduced LOS in spinal surgical patients..Costs and quality of life for prehabilitation and early Costs and quality of life for prehabilitation and early rehabilitation after surgery of the lumbar spine Nielson et rehabilitation after surgery of the lumbar spine Nielson et al. BMC Health Serv Res 2008al. BMC Health Serv Res 2008

Improved cardiovascular exercise parametersImproved cardiovascular exercise parameters..Responsive Measures to Prehabilitation in Patients Responsive Measures to Prehabilitation in Patients Undergoing Bowel Resection Surgery. Kim et al TJEM 2009Undergoing Bowel Resection Surgery. Kim et al TJEM 2009

May be beneficial in certain subgroupsMay be beneficial in certain subgroups

Risk StratificationRisk Stratification

PopulationPopulationAging population with inherent coAging population with inherent co--morbiditymorbidity

High risk patients requiring complex surgery, High risk patients requiring complex surgery, 12.5% of procedures, account for 83.8% of 12.5% of procedures, account for 83.8% of deathsdeaths10 1% mortality in elective procedures admitted 10 1% mortality in elective procedures admitted 10.1% mortality in elective procedures admitted 10.1% mortality in elective procedures admitted to ITU immediately postto ITU immediately post--operativelyoperatively39% mortality in elective procedures admitted to 39% mortality in elective procedures admitted to ward and then ITU postward and then ITU post--operativelyoperatively

Identification and characterisation of the highIdentification and characterisation of the high--risk surgical risk surgical population in the United Kingdom. Pearse et al Crit Care 2006population in the United Kingdom. Pearse et al Crit Care 2006

Laparoscopic surgeryLaparoscopic surgeryMinimal surgical stressMinimal surgical stressMaximal cardiovascular stressMaximal cardiovascular stress

Consideration for exclusion criteriaConsideration for exclusion criteria

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3

Increased oxygen demand periIncreased oxygen demand peri--operativelyoperativelyCardio respiratory reserveCardio respiratory reserveFailure to increase oxygen deliveryFailure to increase oxygen deliveryMisdiagnosis of the problemMisdiagnosis of the problemMi d t di f th blMi d t di f th bl

What goes wrongWhat goes wrong

Misunderstanding of the problemMisunderstanding of the problemMissing the problemMissing the problem

PrePre--operative assessmentoperative assessmentNeed to assess cardiovascular functionNeed to assess cardiovascular functionStatic and dynamic parametersStatic and dynamic parametersStratification of riskStratification of risk

PrePre--operative assessmentoperative assessment

Relationship between the inability to climb two flights of stairs and Relationship between the inability to climb two flights of stairs and outcome after major nonoutcome after major non--cardiac surgery: implications for the cardiac surgery: implications for the prepre--operative assessment of functional capacity. Biccard et al. operative assessment of functional capacity. Biccard et al. Anaesthesia 2005Anaesthesia 2005

Cardiopulmonary exercise testingCardiopulmonary exercise testing

Age > 60Age<60 with CVS disease

Cardiopulmonary exercise testing as a screening tool for Cardiopulmonary exercise testing as a screening tool for perioperative management of major surgery in the elderly. Older perioperative management of major surgery in the elderly. Older et al Chest 1999et al Chest 1999

AT<11

ITU153 pts.

4.6% mortality

AT>11 + ischaemia

HDU115 pts

1.7% mortality

AT >11

Ward280 patients0% mortality

PrePre--operative assessmentoperative assessmentQuestionnaire, Shuttle walk test, CPXQuestionnaire, Shuttle walk test, CPXPoor discrimination of riskPoor discrimination of riskHigh proportion of equivocal resultsHigh proportion of equivocal resultsCPX CPX –– objective measurement of fitnessobjective measurement of fitnessAssessing fitness for surgery: a comparison of questionnaire, Assessing fitness for surgery: a comparison of questionnaire, incremental shuttle walk and cardiopulmonary exercise testing in incremental shuttle walk and cardiopulmonary exercise testing in general surgical patients. Struthers et al. BJA 2008general surgical patients. Struthers et al. BJA 2008

CPX CPX –– anaerobic threshold and peak O2 anaerobic threshold and peak O2 consumptionconsumption

Immediately preImmediately pre--operativelyoperatively

HydrationHydration

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4

Maximising patients hydration pre Maximising patients hydration pre operativelyoperatively

1.Essential1.Essential 64%64%2.Quite Important2.Quite Important 34%34%3.Indifferent3.Indifferent 1%1%4.Not Important4.Not Important 0%0%5.Potentially harmful5.Potentially harmful 0%0%

Insulin resistance after surgeryInsulin resistance after surgery

Worsened by fastingWorsened by fasting

Reduced by regional anaesthetic Reduced by regional anaesthetic

Reduced by less surgical stressReduced by less surgical stress

Prolonged duration postProlonged duration post--operatively operatively

Associated with length of stayAssociated with length of stay

Insulin resistanceInsulin resistance

Insulin resistance is proportional to magnitude of surgeryInsulin resistance is proportional to magnitude of surgery

Insulin resistanceInsulin resistance--a marker of surgical stress.a marker of surgical stress. Thorell et al Curr Opin Clin Nutr Thorell et al Curr Opin Clin Nutr Metab Care 1999Metab Care 1999

Independent predictive factors on Independent predictive factors on length of staylength of stay

Type of surgeryType of surgery

Blood lossBlood loss

Insulin resistance postoperativelyInsulin resistance postoperatively

Carbohydrate loadingCarbohydrate loadingReduces metabolic stressReduces metabolic stressReduces insulin resistanceReduces insulin resistancePatient satisfaction improvedPatient satisfaction improvedEarlier bowel function normalityEarlier bowel function normalityReduces length of stayReduces length of stay

Carbohydrate loadingCarbohydrate loading100 100 g g night before surgerynight before surgery50 50 g g morning of surgerymorning of surgeryFree fluid to 2 hrs preFree fluid to 2 hrs pre--operativelyoperatively

No evidence of aspiration riskNo evidence of aspiration risk

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IntraIntra--operativeoperativening/reorganisation and procedure specPreoperativermation for patients Prehabilitation

cohol and smoking



R i l th i

Postoperative• Effective pain relie

prophylaxis for nausevomiting

cessationutritional support reoperative fluid &rbohydrate intake• Nursing care

Less use ofM h i l b l




• Early mobilisatio• Early oral feedingdietary supplement

L f T b d

IntraIntra--operativeoperativeIndividualised fluid managementIndividualised fluid managementFlow monitoringFlow monitoringOesophageal DopplerOesophageal DopplerAlternative measures of flowAlternative measures of flowAnalgesiaAnalgesia

Avoiding crystalloid overloadAvoiding crystalloid overloadEssentialEssential 72%72%Quite Important 25%Quite Important 25%IndifferentIndifferent 3%3%Not ImportantNot Important 0%0%

Very easy Very easy 25%25%Easy Easy 14%14%Not easy Not easy 47%47%Extremely difficult 14%Extremely difficult 14%

Potentially harmful 0%Potentially harmful 0%

Individualised approachIndividualised approach

Individualised goal directed fluid Individualised goal directed fluid therapytherapy

Essential 58%Essential 58%Quite Important 36%Quite Important 36%IndifferentIndifferent 6%6%

Very easyVery easy 15%15%Easy Easy 41%41%Not easy Not easy 33%33%

Not ImportantNot Important 0%0%Potentially harmful 0%Potentially harmful 0%

Very difficult Very difficult 10%10%

Minimally invasive cardiac outputMinimally invasive cardiac output

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Vigileo/FlotracVigileo/FlotracPulse pressure algorithm from arterial waveformPulse pressure algorithm from arterial waveformMathematical interpretation of waveform with Mathematical interpretation of waveform with anthropometric dataanthropometric dataRepeatedly revised algorithmRepeatedly revised algorithmN t l lib tiN t l lib tiNo external calibrationNo external calibration

Second algorithm relatively inaccurate Second algorithm relatively inaccurate

Vigileo/FlotracVigileo/FlotracMost recent algorithmMost recent algorithmCompared with PAFC, TTECompared with PAFC, TTESVV 10% and PPV 12% highly predictive of fluid SVV 10% and PPV 12% highly predictive of fluid responsivenessresponsivenessCVP d PAOP CVP d PAOP di tidi tiCVP and PAOP nonCVP and PAOP non--predictivepredictive

Uncalibrated pulse contourUncalibrated pulse contour--derived stroke volume variation derived stroke volume variation predicts fluid responsiveness in mechanically ventilated patients predicts fluid responsiveness in mechanically ventilated patients undergoing liver transplantation. Biais et al BJA 2008undergoing liver transplantation. Biais et al BJA 2008

Vigileo/FlotracVigileo/FlotracTOE vs pulse contour analysisTOE vs pulse contour analysisMeasurements at lithotomy, pneumoperitoneum Measurements at lithotomy, pneumoperitoneum and falls in pressure below baselineand falls in pressure below baselinePercentage error of 40% between modalitiesPercentage error of 40% between modalities

Concha et al. Pulse contour analysis and transesophageal Concha et al. Pulse contour analysis and transesophageal echocardiography: a comparison of measurements of cardiac echocardiography: a comparison of measurements of cardiac output during laparoscopic colon surgery. Anesth Analg 2009output during laparoscopic colon surgery. Anesth Analg 2009

Vigileo/FlotracVigileo/FlotracPulse Contour analysis vs. ODMPulse Contour analysis vs. ODMIntraIntra--abdominal surgeryabdominal surgeryPoor predictor of fluid responsivenessPoor predictor of fluid responsiveness

Lahner et al. Evaluation of stroke volume variation obtained by Lahner et al. Evaluation of stroke volume variation obtained by Lahner et al. Evaluation of stroke volume variation obtained by Lahner et al. Evaluation of stroke volume variation obtained by arterial pulse contour analysis to predict fluid responsiveness arterial pulse contour analysis to predict fluid responsiveness intraoperatively. BJA 2009intraoperatively. BJA 2009

LiDCOLiDCOrapidrapidDesigned for use in operating theatreDesigned for use in operating theatrePulseCo arterial algorithmPulseCo arterial algorithmValidated over variety of clinical situationsValidated over variety of clinical situationsProvides a nominal stroke volumeProvides a nominal stroke volumeAccurate trending of stroke volumeAccurate trending of stroke volumePredictive of fluid responsiveness using SVV and Predictive of fluid responsiveness using SVV and PPVPPV

Pulse pressure variationPulse pressure variation33 elective high33 elective high--risk intrarisk intra--abdominal surgical abdominal surgical patientspatientsIntervention arm received HAES 6% boluses to Intervention arm received HAES 6% boluses to minimise and maintain PPV <10% intraminimise and maintain PPV <10% intra--operativelyoperativelyAt PPV<10%, further fluid boluses are unlikely to At PPV<10%, further fluid boluses are unlikely to improve SVimprove SVIntervention group received more fluid, had less Intervention group received more fluid, had less complications(1.4 vs. 3.9, p<0.05) and reduced complications(1.4 vs. 3.9, p<0.05) and reduced hospital stay(7 vs. 17 days, p<0.01)hospital stay(7 vs. 17 days, p<0.01)Lopes et al. GoalLopes et al. Goal--directed fluid management based on pulse directed fluid management based on pulse pressure variation during high risk surgery: a pilot randomised pressure variation during high risk surgery: a pilot randomised controlled trial. Crit Care 2007 controlled trial. Crit Care 2007

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Thoracic bioimpedenceThoracic bioimpedence Nasogastric tubeNasogastric tube

Prophylactic decompressionProphylactic decompressionSlows return of bowel function, Slows return of bowel function, p<0.00001.p<0.00001.Trend to increased pulmonary Trend to increased pulmonary Trend to increased pulmonary Trend to increased pulmonary complications, vomiting and patient complications, vomiting and patient discomfort.discomfort.

Nelson et al. Nelson et al. Nasogastric decompression used routinely after Nasogastric decompression used routinely after abdominal surgery does not speed recovery . Cochrane Datrabase abdominal surgery does not speed recovery . Cochrane Datrabase of systematic reviews 2007of systematic reviews 2007

PostPost--operativeoperativening/reorganisation and procedure specPreoperativermation for patients Prehabilitation

cohol and smoking



Postoperativ• Effective pain relie

prophylaxis for nausvomiting

E l bili tcessationutritional support reoperative fluid &rbohydrate intake• Nursing care

Less use ofM h i l b l




L f D i d

• Early mobilisat• Early oral feedingdietary supplemen

PostPost--operative optimisationoperative optimisation162 general surgical patients162 general surgical patientsConventional vs. goal directed therapyConventional vs. goal directed therapy8 hours post operatively8 hours post operativelyIntervention group Intervention group –– colloid +/colloid +/-- dopexamine to dopexamine to achieve target DOachieve target DO22I of 600 ml/min/mI of 600 ml/min/m22

C t l C t l ll id t hi t i d i f ll id t hi t i d i f Control arm Control arm –– colloid to achieve sustained rise of colloid to achieve sustained rise of 2 mmHg in CVP2 mmHg in CVPLess complications(44% vs. 68%, p=0.003) and Less complications(44% vs. 68%, p=0.003) and reduced hospital stay (11 vs. 14 days, p=0.001)reduced hospital stay (11 vs. 14 days, p=0.001)

Early goalEarly goal--directed therapy after major surgery reduces directed therapy after major surgery reduces complications and duration of hospital stay. Pearse et al. Crit Care complications and duration of hospital stay. Pearse et al. Crit Care 20052005

PostPost--operativeoperativeEffective pain relief Effective pain relief Nausea and vomiting limitationNausea and vomiting limitation

Early mobilisation Early mobilisation –– 2 hours day 12 hours day 1Day 2 Day 2 -- 6 hours mobilisation6 hours mobilisationDay 2 Day 2 -- 6 hours mobilisation6 hours mobilisation

Early oral feeding and dietary supplementationEarly oral feeding and dietary supplementationLess use of Tubes, drains and cathetersLess use of Tubes, drains and catheters

Early nutritional supportEarly nutritional supportEncourage oral fluid in recoveryEncourage oral fluid in recovery

Immediate nutrition with epidural analgesiaImmediate nutrition with epidural analgesiaImproved mobility (5.5 vs. 1.7 hrs/day)Improved mobility (5.5 vs. 1.7 hrs/day)Improved protein and calorific intakeImproved protein and calorific intakeEarly oral nutrition after elective colorectal surgery: influence of Early oral nutrition after elective colorectal surgery: influence of balanced analgesia and enforced mobilisation. Henriksen et al. balanced analgesia and enforced mobilisation. Henriksen et al. Nutrition 2002Nutrition 2002

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Less tubes, drains and cathetersLess tubes, drains and catheters

Epidural cathetersEpidural catheters

Central venous cathetersCentral venous cathetersCentral venous pressure monitoringCentral venous pressure monitoringCentral venous saturation monitoringCentral venous saturation monitoring

ScvOScvO22

PeriPeri--operative factorsoperative factorsHypoxiaHypoxiaShiveringShiveringAnaemiaAnaemiaMyocardial ischaemiaMyocardial ischaemiaMyocardial ischaemiaMyocardial ischaemia

Correlates well with SvO2Correlates well with SvO2Poor correlation with DO2Poor correlation with DO2Comparison of central venous oxygen saturation and mixed Comparison of central venous oxygen saturation and mixed venous oxygen saturation during liver transplantation. El Masry venous oxygen saturation during liver transplantation. El Masry et al. Anaesthesia 2009et al. Anaesthesia 2009

ScvOScvO22

8 hours Post8 hours Post--operative ScvO2operative ScvO2Target for complications Target for complications –– 64.4%64.4%Fall immediately postFall immediately post--opopSignificant fluctuation in ScvO2Significant fluctuation in ScvO2Fluctuations not related to DO2Fluctuations not related to DO2Fluctuations not related to DO2Fluctuations not related to DO2No change in C.I.No change in C.I.

Changes in central venous saturation after major surgery, and Changes in central venous saturation after major surgery, and association with outcome. Pearse et al. Critical Care 2005, association with outcome. Pearse et al. Critical Care 2005, 9:R6949:R694--9696

PeriPeri--operative fluid requirementoperative fluid requirement

Fluid Requirement

1 2 3 4 5 6 7 8 9 10

Time

PeriPeri--operative fluid monitoringoperative fluid monitoringHow long to monitor the patient?How long to monitor the patient?Do we need ScvO2?Do we need ScvO2?Do we need a Central Venous Catheter?Do we need a Central Venous Catheter?Individualised, monitored approach or...Individualised, monitored approach or...All patients to receive fluid bolus at 8 hours?All patients to receive fluid bolus at 8 hours?

PostPost--operative careoperative careDedicated area may improve resultsDedicated area may improve results

Staff relatedStaff relatedOrganisationalOrganisational

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PostPost--operative courseoperative course

3 patient groups3 patient groups1. Meet discharge criteria1. Meet discharge criteria2. Delay to discharge criteria2. Delay to discharge criteria3. Criteria met but discharge delayed3. Criteria met but discharge delayed

Is a protocol enough?Is a protocol enough?5 centre study5 centre study425 patients425 patientsLow compliance with protocol postLow compliance with protocol post--operativelyoperativelyGoal of readiness for discharge on day 3Goal of readiness for discharge on day 3High number of patients discharged on day 5High number of patients discharged on day 5

Need repeated team meetings/ discussions etcNeed repeated team meetings/ discussions etc

A protocol is not enough to implement an enhanced recovery A protocol is not enough to implement an enhanced recovery programme for colorectal resection Maessen et al. BJS 2007programme for colorectal resection Maessen et al. BJS 2007

Policy changePolicy changeHistorical matched studyHistorical matched studyDelay in discharge from preDelay in discharge from pre--set criteriaset criteriaImproved since introduction of ERAS programmeImproved since introduction of ERAS programmeMain reason for delayMain reason for delay-- wound carewound careReduction in length of stay related to changes in Reduction in length of stay related to changes in local staff policylocal staff policy

ERAS group. Length of Stay: An Inappropriate Readout of the ERAS group. Length of Stay: An Inappropriate Readout of the Success of Enhanced Recovery Programs. World J Surg 2008Success of Enhanced Recovery Programs. World J Surg 2008

Additional factorsAdditional factorsAudit and ongoing assessmentAudit and ongoing assessment

DocumentationDocumentationHospital stayHospital stayMorbidityMorbidityMorbidityMorbiditySafetySafetyCostCostPatient satisfactionPatient satisfactionPatient follow upPatient follow up

Patient SafetyPatient SafetyRobust protocolised approachRobust protocolised approachSafety net for dischargesSafety net for dischargesImproving qualityImproving qualityImproving educationImproving educationAuditAudit

Patient safetyPatient safetyMetaMeta--analysis 1021 patientsanalysis 1021 patientsReduced length of stayReduced length of stayReduced morbidityReduced morbidityNo difference in readmission ratesNo difference in readmission ratesNo difference in mortalityNo difference in mortality

FastFast--track vs standard care in colorectal surgery: a metatrack vs standard care in colorectal surgery: a meta--analysis analysis update. Gouvas et al. Int J Col Dis 2009. update. Gouvas et al. Int J Col Dis 2009.

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Patient outcomePatient outcome183 historical matched patients183 historical matched patientsERAS vs conventional morbidity 14.8% vs ERAS vs conventional morbidity 14.8% vs 33.6%, p<0.0133.6%, p<0.01Hospital stay 6 vs. 9 days, p=0.03Hospital stay 6 vs. 9 days, p=0.03N diff i t litN diff i t litNo difference in mortalityNo difference in mortalityNo difference in readmission ratesNo difference in readmission rates

Enhanced recovery after surgery versus conventional Enhanced recovery after surgery versus conventional postoperative care in colorectal surgery. Teeuwen et al. J postoperative care in colorectal surgery. Teeuwen et al. J Gastrointest Surg 2009Gastrointest Surg 2009

ConclusionConclusionMultiMulti--disciplinary approachdisciplinary approachEducationEducationPatient selection and stratificationPatient selection and stratificationIndividualised managementIndividualised managementProtocolised managementProtocolised management

REVIEW ARTICLE

Consensus Review of Optimal Perioperative Carein 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-mal perioperative care in colorectal surgery and toprovide consensus recommendations for each item ofan evidence-based protocol for optimal perioperativecare.

Data Sources: For every item of the perioperative treat-ment pathway, available English-language literature hasbeen examined.

Study Selection: Particular attention was paid to meta-analyses, randomized controlled trials, and systematicreviews.

Data Extraction: A consensus recommendation for eachprotocol item was reached after critical appraisal of theliterature by the group.

Data Synthesis: For most protocol items, recommen-dations are based on good-quality trials or meta-analyses of such trials.

Conclusions: The Enhanced Recovery After Surgery(ERAS) Group presents a comprehensive evidence-basedconsensus review of perioperative care for colorectal sur-gery. It is based on the evidence available for each elementof the multimodal perioperative care pathway.

Arch Surg. 2009;144(10):961-969

F AST-TRACK OR ENHANCED-recoveryprogramsintegratearange of perioperative inter-ventions proven to maintainphysiological functionandfa-

cilitatepostoperativerecovery,especiallyaf-ter elective colonic resections in dedicatedcenters.1-4TheEnhancedRecoveryAfterSur-gery(ERAS)Grouphasachievedsimilar re-sults in general surgical departments usingan evidence-based care platform.5,6

We present an updated and expandedconsensus review of perioperative care forcolorectal surgery based on the evidenceavailable for each element of the multi-modal pathway.

METHODS

The MEDLINE database was searched up to De-cember 31, 2007 (3 exceptions were made: 2meta-analyses and an editorial published in2008), and the ERAS protocol6 from 2005 wasupdated. Recommendations were evaluated ac-cording to the system developed by the Centrefor Evidence Based Medicine, Oxford, En-gland.7 Those based on at least 2 good-qualityrandomized controlled trials (RCTs) (in pa-tients undergoing gastrointestinal surgery) or 1

meta-analysis of RCTs with homogeneity weredesignated as grade A. Other recommendationswere designated as consensus recommenda-tions based on the best available evidence. Theevidence is presented in the text and the recom-mendations are summarized in the Table.

RESULTS

PREADMISSION INFORMATIONAND COUNSELING

Explicitpreoperative informationcanfacili-tatepostoperativerecoveryandpaincontrol,particularly inpatientsexhibitingdenialandanxiety.8,9Aclearexplanationofexpectationsduringhospitalization facilitatesadherenceto the care pathway and allows early recov-ery and discharge.10,11 At this first encoun-ter, the patient should also be given a clearrolewithspecific tasks, includingtargets forpostoperative food intake, oral nutritionalsupplements, and mobilization.12,13

PREOPERATIVEBOWEL PREPARATION

Mechanical bowel preparation can cause de-hydration and fluid and electrolyte abnor-

Author Affiliations are listed atthe end of this article.Group Information: TheEnhanced Recovery AfterSurgery (ERAS) Groupmembers are listed at the end ofthis article.

(REPRINTED) ARCH SURG/ VOL 144 (NO. 10), OCT 2009 WWW.ARCHSURG.COM961

©2009 American Medical Association. All rights reserved. at University of Nottingham, on October 19, 2009 www.archsurg.comDownloaded from

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malities, particularly in elderly patients.14 Two recent large,multicenter RCTs15,16 confirm the conclusions of earliermeta-analyses17-19 that bowel preparation is not beneficialin elective colonic surgery, and 2 smaller recent RCTs sug-gest that it increases the risk for anastomotic leak.20,21 Bucheret al20 included only left-sided colonic resections and dem-onstrated increased morbidity after routine bowel cleans-ing. Bowel preparation may be necessary in selected pa-tients who require intraoperative colonoscopy. For colonicsurgery, data indicate that bowel preparation is stressful andprolongs postoperative ileus.22

A 2005 Cochrane analysis23 included 231 low ante-rior resections without finding an increased leak ratein those without bowel preparation. A recent RCT thatincluded a substantial proportion of ultralow rectalanastomoses24 reported that bowel preparation pro-tects against anastomotic leaks requiring reoperations.There was, however, increased cardiovascular mortal-ity in the group receiving bowel preparation. Furthertrials are needed to establish the optimal routine forvery low rectal resections. Nevertheless, logic dictatesthat the bowel distal to the stoma should be cleansed if

Table. Consensus Guidelines

Item Guideline

Preadmission information and counseling Patients should receive oral and written preadmission information describing what will happen duringhospitalization, what they should expect, and what their role is in the recovery process.

Preoperative bowel preparation Patients undergoing elective colonic resection above the peritoneal reflection should not receive routineoral bowel preparation (grade A). Bowel preparation may be considered in patients scheduled for lowrectal resection where a diverting stoma is planned.

Preoperative fasting and preoperativecarbohydrate loading

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).

Preanesthetic medication Patients should not receive medications known to cause long-term sedation, from midnight prior tosurgery. Short-acting medications given to facilitate insertion of epidural catheter are acceptable(grade A).

Prophylaxis against thromboembolism The preferred methods for prophylaxis in patients undergoing elective colorectal surgery aresubcutaneous low-dose unfractionated heparin or subcutaneous low-molecular-weight heparin(grade A).

Antimicrobial prophylaxis Patients undergoing colorectal resection should receive single-dose antibiotic prophylaxis against bothanaerobes and aerobes about 1 hour before surgery (grade A).

Standard anesthetic protocol Long-acting opioids should be avoided in patients undergoing anesthesia. Patients should receive amidthoracic epidural commenced preoperatively and containing local anesthetic in combination with alow-dose opioid (grade A).

Preventing and treating postoperativenausea and vomiting

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.

Laparoscopy-assisted surgery Laparoscopic colonic resection is recommended if the surgeon or department is proficient with thetechnique and prospectively validated outcomes show at least equivalence to open surgery (grade A).

Surgical incisions A midline or transverse laparotomy incision of minimal length should be used for patients undergoingelective colorectal resection.

Nasogastric intubation Nasogastric tubes should not be used routinely in the postoperative period (grade A). They should beinserted if ileus develops.

Preventing intraoperative hypothermia Intraoperative maintenance of normothermia with an upper-body forced-air heating cover should be usedroutinely (grade A).

Perioperative fluid management Intraoperative and postoperative fluid restriction in major colonic surgery with avoidance of hypovolemiais safe (grade A). When compared with excessive fluid regimens, normovolemic regimens in majorcolonic 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 tooutcome (grade A) and should be considered on an individual basis.

Drainage of peritoneal cavity followingcolonic anastomosis

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.

Urinary drainage Suprapubic urinary drainage for pelvic surgery is recommended (grade A). For colonic surgery, bothsuprapubic and urethral techniques are appropriate.

Prevention of postoperative ileus Midthoracic epidural analgesia and avoidance of fluid overload are recommended to preventpostoperative 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.

Postoperative analgesia Patients should receive continuous epidural midthoracic low-dose local anesthetic and opioidcombinations (grade A) for approximately 48 hours following elective colonic surgery andapproximately 96 hours following pelvic surgery. Acetaminophen (paracetamol) should be used as abaseline analgesic (4 g/d) throughout the postoperative course. For breakthrough pain, epiduralboluses should be given while the epidural is running. Nonsteroidal anti-inflammatory drugs should bestarted at removal of the epidural.

Postoperative nutritional care Patients should be encouraged to commence an oral diet at will after surgery (grade A). Oral nutritionalsupplements should be prescribed (approximately 200 mL, energy dense, 2-3 times daily) from theday of surgery until normal food intake is achieved. Continuation of oral nutritional supplements athome for several weeks is recommended for nutritionally depleted patients (grade A).

Early mobilization Patients should be nursed in an environment that encourages independence and mobilization. A care planthat facilitates patients being out of bed for 2 hours on the day of surgery and 6 hours thereafter isrecommended.

Audit A systematic audit should be performed to allow direct comparison with other institutions.




a diverting stoma is constructed to protect theanastomosis.

PREOPERATIVE FASTING AND PREOPERATIVECARBOHYDRATE LOADING

Although fasting from midnight has been standard prac-tice to avoid pulmonary aspiration in elective surgery, a re-view has found no evidence to support this.25 Equally, aCochrane review26 of 22 RCTs in adult patients providesrobust evidence that reducing the preoperative fasting pe-riod for clear fluids to 2 hours does not increase compli-cations. National Anaesthesia Societies now recommendintake of clear fluids until 2 hours before induction of an-esthesia as well as a 6-hour fast for solid food.27-30 Obeseandevenmorbidlyobesepatientshave the samegastric emp-tying characteristics as lean patients.31,32 Diabetic patientswith neuropathy may have delayed gastric emptying, pos-sibly increasing the risk of regurgitation and aspiration.33

Patients with uncomplicated type 2 diabetes mellitus canhave normal gastric emptying, and a study of preoperativecarbohydrate loading did not find increased aspiration ratesin such patients.34

Having patients undergo surgery in a metabolically fedstate can be achieved by provision of a clear carbohydrate-rich beverage before midnight and 2 to 3 hours beforesurgery.This reducespreoperative thirst,hunger, andanxi-ety26,35 and postoperative insulin resistance.36 Patients ina more anabolic state have less postoperative nitrogen andprotein losses37,38 as well as better-maintained lean bodymass39 and muscle strength.40 Data from RCTs indicateaccelerated recovery and shorter hospital stay in pa-tients receiving preoperative carbohydrate loading in co-lorectal surgery.41,42

PREANESTHETIC MEDICATION

Adverse effects from long-acting premedication such asopioids, long-acting sedatives, and hypnotics hamper re-covery (eg, immediate ability to drink and mobilizationafter surgery), leading to prolonged length of stay.43 Short-acting anxiolytics do not prolong recovery or length ofstay.44

PROPHYLAXIS AGAINST THROMBOEMBOLISM

Meta-analyses have shown subcutaneous low-dose un-fractionated heparin regimens to be effective in reducingdeep vein thrombosis, pulmonary embolism, and mortal-ity in patients undergoing colorectal surgery.45-48 Meta-analyses comparing low-molecular-weight heparin(LMWH) with unfractionated heparin have shown no dif-ference in efficacy47,48 or associated bleeding risks.49,50 TheLMWH is preferable because of its once-daily dosage anda lower risk of heparin-induced thrombocytopenia.50-52

Although antiplatelet drugs and intravenous dextranare less effective for prophylaxis of deep vein thrombo-sis and in reducing mortality, they can be as effective forthe prevention of pulmonary embolism.48,53 Their ad-verse effect profiles53,54 make them advisable only in high-risk patients when LMWH and unfractionated heparinare contraindicated.

The safety of continuing LMWH and continuous epi-dural analgesia is debatable. In the United States, higherdoses of LMWH are used twice daily and may accountfor the greater numbers of epidural hematomas re-ported.55 Prophylactic doses of LMWH should be givenno later than 12 hours prior to insertion and removal ofan epidural catheter.56,57 Although concomitant use of non-steroidal anti-inflammatory drugs and LMWH is consid-ered safe, a potential link with epidural hematoma is de-bated. Care should be taken with other factors affectingcoagulation, and alternative thromboprophylaxis (suchas thromboembolism-deterrent stockings) should be usedwhen appropriate.

ANTIMICROBIAL PROPHYLAXIS

The use of prophylactic antibiotics effective against bothaerobes and anaerobes can minimize infectious compli-cations in colorectal surgery,58 with the first dose beingadministered about 1 hour prior to skin incision.59 A singledose is as effective as multidose regimens, but further dosesshould be given in prolonged cases (�3 hours).58 Theoptimal combination of antibiotics is not established, buta second-generation cephalosporin and metronidazole aresuggested. New generations of antibiotics should be re-served for infectious complications.

STANDARD ANESTHETIC PROTOCOL

There is no evidence to direct the choice of the optimal an-esthetic method for colorectal procedures. However, it isrational to use short-acting agents (propofol, remifentanilhydrochloride)60 instead of long-acting intravenous opi-oids (morphine sulfate, morphine hydrochloride, fen-tanyl citrate), thereby allowing proactive recovery to startsoon after surgery. Short-acting inhalational anesthesia isa reasonable alternative to total intravenous anesthesia.There is no evidence that intraoperative epidural analge-sia improves postoperative outcome in colorectal proce-dures, but its use reduces the dose of general anestheticagents. For colonic surgery, the epidural catheter is bestplaced at the midthoracic level (T7/8) to achieve both an-algesia and sympathetic blockade, preventing gut paraly-sis.61 If activated before commencement of surgery, it blocksstress hormone release and attenuates postoperative insu-lin resistance.62 The catheter is inserted in the awake pa-tient to avoid neurological complications. Intraopera-tively, the block can be maintained by continuous infusionof local anesthetic (eg, bupivacaine hydrochloride, 0.1%-0.25%, or ropivacaine hydrochloride, 0.2%) plus a low-dose opiate (eg, 2.0-µg/mL fentanyl citrate or 0.5- to 1.0-µg/mL sufentanil citrate) at 4 to 10 mL/h. Epidural opioidsin small doses act synergistically with epidural local anes-thetics in providing analgesia,63 without major systemic ef-fects.64-66 Addition of epinephrine (1.5- to 2.0-µg/mL) tothe thoracic epidural infusion improves analgesia.67-69

PREVENTING AND TREATINGPOSTOPERATIVE NAUSEA AND VOMITING

Patient experience suggests that postoperative nausea andvomiting can be more stressful than pain.70-73 Risk fac-




tors include being female and having nonsmoking sta-tus, history of motion sickness (or postoperative nauseaand vomiting), and postoperative administration of opi-oids.74,75 Individuals at moderate risk (2 factors) shouldreceive prophylaxis with dexamethasone sodium phos-phate at induction or serotonin receptor antagonist at theend of surgery.76 High-risk individuals (3 factors) shouldreceive general anesthesia with propofol and remifenta-nil as well as 4 to 8 mg of dexamethasone sodium phos-phate at the beginning of surgery, supplemented with sero-tonin receptor antagonists or droperidol76 or with 25 to50 mg of metoclopramide hydrochloride 30 to 60 min-utes before the end of surgery.77

LAPAROSCOPY-ASSISTED SURGERY

The most recent meta-analysis78 confirms that signifi-cant improvements in short-term outcomes are achiev-able by laparoscopy-assisted colonic resection as a singleintervention. This was associated with significant reduc-tions in short-term wound morbidity, time to first bowelmovement, and discharge from the hospital.

The potential of combining laparoscopy and enhanced-recovery care has been evaluated in only 2 small trialsrandomizing patients to either laparoscopy-assisted oropen surgery within an established enhanced-recoveryprotocol.79,80 In the setting of a long-established and ef-ficient enhanced-recovery protocol, no further improve-ment in short-term outcome was seen by adding lapa-roscopy (median postoperative length of stay of 2 daysin both groups).79 The second study had longer hospi-talizations, and here a reduction in postoperative stay wasseen in the laparoscopy-assisted group as compared withthe group undergoing open surgery (3.5 vs 6 days,respectively).80 Further investigation will hopefully moreclearly evaluate the full potential of combining laparos-copy and enhanced-recovery care.81

SURGICAL INCISIONS

Some RCTs suggest that transverse or curved incisionscause less pain and pulmonary dysfunction than verti-cal incisions following abdominal procedures,82,83 whileothers have found no advantage of transverse inci-sions.84,85 A recent Cochrane review86 of RCTs compar-ing midline with transverse incisions for abdominal sur-gery confirms that although analgesic use and pulmonarycompromise may be reduced with transverse or obliqueincisions, complication rates and recovery times are thesame as with midline incisions. Hence, while incisionlength affects patient recovery,87 the choice of incisionfor abdominal surgery still remains the preference of thesurgeon.

NASOGASTRIC INTUBATION

A meta-analysis88 in 1995 showed that routine nasogas-tric decompression should be avoided after colorectal sur-gery since fever, atelectasis, and pneumonia are re-duced in patients without a nasogastric tube. A recentCochrane meta-analysis89 of 33 trials with more than 5000patients confirmed this and also found earlier return of

bowel function in patients when nasogastric decompres-sion was avoided. Gastroesophageal reflux is increasedduring laparotomy if nasogastric tubes are inserted,90 andthere is no rationale for routine insertion of a nasogas-tric tube during elective colorectal surgery, except toevacuate air that may have entered the stomach duringventilation by facial mask prior to endotracheal intuba-tion. Nasogastric tubes placed during surgery should beremoved before reversal of anesthesia.

PREVENTING INTRAOPERATIVE HYPOTHERMIA

Several RCTs have demonstrated that preservation of nor-mothermia by using an upper-body forced-air heatingcover reduces wound infections,91,92 cardiac complica-tions,92-94 bleeding, and transfusion requirements.92,95 Ex-tending systemic warming to 2 hours before and after sur-gery had additional benefits.96

PERIOPERATIVE FLUID MANAGEMENT

It has been standard practice in recent years to infuse vol-umes of intravenous fluids substantially in excess of ac-tual perioperative losses.97 Traditional perioperative in-travenous fluid regimens in abdominal surgery can leadto patients receiving 3.5 to 7 L of fluid on the day of sur-gery 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 candelay the return of normal gastrointestinal function,98 im-pair wound or anastomotic healing, and affect tissue oxy-genation, leading to prolonged hospitalization.99,100 Sev-eral trials have compared restrictive and liberal fluid orsodium regimens.98-102 The results are not uniform andcomparison is difficult as administered volumes and elec-trolytes in both arms differed substantially, reflecting non-uniform standard practice.

However, evidence does suggest that avoidance of over-load and restricting fluid intake to that which will main-tain balance, guided by body weight, may significantlyreduce postoperative complications and shorten hospi-tal stay and should therefore be recommended.98,100 Thebest way to limit postoperative intravenous fluid admin-istration is to stop intravenous infusions and return tooral fluids early, which should be feasible on the first post-operative day.1 Patients with epidural anesthesia expe-riencing hypotension due to vasodilation and relative in-travascular hypovolemia, which is traditionally treatedwith fluid loading, can be treated with the judicious useof a vasopressor.103

Intraoperative transesophageal Doppler monitoringhelps titrate fluids in relation to cardiac output and maybe useful in high-risk patients. Four RCTs104-107 and a meta-analysis108 with patients undergoing major bowel sur-gery found that when intraoperative fluid administra-tion was guided by transesophageal Doppler monitoring,there was a better ejection fraction, better oxygenation,and fewer postoperative complications. Although pa-tients in these trials were not treated according to en-hanced-recovery protocols, it seems that transesopha-geal Doppler monitoring enables optimization ofintravascular volume and tissue perfusion in major ab-dominal surgery. In low-risk patients undergoing sur-




gery of moderate magnitude, flow-guided therapy maynot be warranted. High-grade evidence regarding the op-timal regimen in terms of timing, type of fluid, and riskstratification is currently lacking.

DRAINAGE OF PERITONEAL CAVITYFOLLOWING COLONIC ANASTOMOSIS

Meta-analyses109,110 have demonstrated that the use ofdrains after colonic surgery does not reduce the inci-dence or severity of anastomotic leaks or other compli-cations. Drainage of the pelvic cavity for 24 hours fol-lowing low anterior resection is supported by the Dutchtotal mesorectal excision trial,111 although this remainsto be proven in RCTs specifically designed to answer thisquestion.

URINARY DRAINAGE

A recent meta-analysis112 of RCTs concluded that supra-pubic catheterization is more acceptable to patients andreduces morbidity compared with urethral catheteriza-tion. Most trials have been undertaken in patients re-quiring 4 to 7 days of urinary drainage. The risk of uri-nary retention after only 24 hours of catheterization islow after colonic resection above the peritoneal reflec-tion during epidural analgesia.113 Therefore, the advan-tages of suprapubic over urethral catheterization are prob-ably small for colonic surgery, while the benefits aresignificant for pelvic surgery with longer catheteriza-tion times.

PREVENTION OF POSTOPERATIVE ILEUS

Prevention of postoperative ileus, a major cause of de-layed discharge after abdominal surgery, is a key objec-tive of enhanced-recovery protocols. While no currentprokinetic agent is effective in attenuating or treating post-operative ileus, several other interventions have been suc-cessful. Midthoracic epidural analgesia61 as compared withintravenous opioid analgesia is highly efficient at pre-venting postoperative ileus.65,114 Fluid overloading dur-ing101 and after98 surgery impairs gastrointestinal func-tion and should be avoided. Oral magnesium oxidehas been demonstrated to promote postoperative bowelfunction in a double-blinded RCT in abdominal hyster-ectomy115 and in reports from a well-established enhanced-recovery program in colonic resection.1,116 Laparoscopy-assisted colonic resection also leads to faster return ofbowel function as well as resumption of an oral diet com-pared with open surgery.78 Oral alvimopan, a µ-opioidreceptor antagonist approved for clinical use in postop-erative ileus, accelerates gastrointestinal recovery and re-duces the duration of hospitalization in patients under-going colonic resection compared with postoperativeintravenous opioid analgesia.117

POSTOPERATIVE ANALGESIA

Meta-analyses have shown that optimal analgesia isachieved by continuous epidural local anesthetic with orwithout opioids for 2 to 3 days postoperatively in both

open64,114 and laparoscopic118 surgery. Analgesia based onintravenous opioids does not provide the same efficientanalgesia114 and has fewer beneficial effects on surgicalstress responses compared with epidural local anes-thetic techniques. While it is possible to achieve almostthe same pain scores with patient-controlled analgesiaat rest compared with epidural analgesia, this is at theexpense of patients remaining sedated and in bed. SomeRCTs114,119 have demonstrated that continuous epidurallocal anesthetic techniques reduce pulmonary morbid-ity but not other types of morbidity, hospital stay, orconvalescence.

There are some concerns about the risk of anastomoticcomplications after epidural analgesia for colonic resec-tion.114,120,121 Perfusion of the splanchnic area after estab-lishment of the epidural block is probably more closely as-sociated with changes in mean arterial pressure than withchanges in cardiac output.122 Therefore, vasopressors tomaintain pressure should be considered. In the case of car-diac insufficiency, an adequate preload and positive ino-tropes are mandatory to improve colonic blood flow. Low-dose norepinephrine and dobutamine hydrochloride areprobably not harmful for splanchnic perfusion.123-127 Theunanswered questions are the acceptable range of bloodpressure in individual patients and the duration for whichvasopressors should be used.120

Avoidance of opioids and their adverse effects is thegoal after removal of the epidural catheter, and nonste-roidal anti-inflammatory drugs have been shown to beopioid sparing128 and to provide efficient analgesia dur-ing this period.1,129 Nabumetone is a widely used non-steroidal anti-inflammatory drug that does not affect bleed-ing time and may be a safer choice in patients withepidurals.130

POSTOPERATIVE NUTRITIONAL CARE

The RCTs of early enteral or oral feeding vs “nil by mouth”conclude that there is no advantage of keeping patientsfasted after elective gastrointestinal resection.131-133 Earlyfeeding reduced both the risk of infection and the lengthof hospital stay and was not associated with an in-creased risk of anastomotic dehiscence. However, the riskof vomiting increased in patients fed early, and in the ab-sence of multimodal anti-ileus therapy, early feeding wasassociated with bloating, impaired pulmonary function,and delayed mobilization.134,135

For malnourished patients, there is a clear advantageof prescribing postoperative oral nutritional supple-ments for 8 weeks in terms of recovery of nutritional sta-tus, protein economy, and quality of life.136 Positive clini-cal outcomes from oral nutrition supplements have alsobeen documented in studies of patients undergoing elec-tive surgery who are not screened for malnutrition.137,138

In enhanced-recovery programs, oral nutritional supple-ments have been used successfully on the day prior tooperation and for at least the first 4 postoperative daysto achieve recommended intakes of energy and pro-tein.1,139,140 When used in combination, preoperative oralcarbohydrate loading, epidural analgesia, and early en-teral nutrition have been shown to result in nitrogen equi-librium without concomitant hyperglycemia.141




EARLY MOBILIZATION

Bed rest not only increases insulin resistance and muscleloss but also decreases muscle strength, pulmonary func-tion, and tissue oxygenation.142 Additionally, there is anincreased risk of thromboembolism. Effective pain re-lief using ambulatory thoracic epidural analgesia is a keyadjuvant measure to encourage postoperative mobiliza-tion. A prescheduled care plan should list daily goals formobilization, and a patient diary for out-of-bed activi-ties is helpful. It is essential that the patient is nursed inan environment that encourages early mobilization (foodand television removed from the bedroom) and one thatmaintains the patient’s independence (ordinary ward orlevel 1 facility). The aim is for patients to be out of bedfor 2 hours on the day of surgery and for 6 hours per dayuntil discharge. Abdominal drains and urinary cath-eters hinder mobilization and should be avoided when-ever possible.

AUDIT

A systematic audit is mandatory to determine clinical out-come and to establish the successful implementation ofthe care protocol. Distinguishing between unsuccessfulimplementation and lack of desired effect from an imple-mented protocol is vital if results are short of desired qual-ity standards. Comparison with other centers using simi-lar protocols via identical tools of registration and identicaldefinitions of key factors is needed.

COMMENT

This article outlines the recommendations of the ERASGroup for clinical perioperative care of patients under-going elective colorectal surgery, based on the best avail-able evidence. However, neither evidence nor protocolis sufficient to ensure evidence-based care. Evidence dic-tates care only to a very limited extent,143 and an evidence-based protocol alone is insufficient to ensure change.144

We echo the words of Urbach and Baxter: “the immedi-ate challenge to improving the quality of surgical care isnot discovering new knowledge, but rather how to in-tegrate what we already know into practice.”145

Accepted for Publication: October 21, 2008.Author Affiliations: Department of Gastrointestinal Sur-gery, University Hospital Northern Norway and Insti-tute of Clinical Medicine, University of Tromsø, Tromsø,Norway (Drs Lassen, Revhaug, and Norderval); Depart-ment of Surgery, Faculty of Medical and Health Sci-ences, University of Auckland, Grafton, Auckland, NewZealand (Dr Soop); Department of Surgery, Ersta Hos-pital (Dr Nygren), Department of Clinical Sciences, Dan-deryd Hospital, Karolinska Institutet (Dr Nygren), andDivision of Surgery, Karolinska Institutet, CLINTEC,Karolinska University Hospital Huddinge (Dr Ljungqvist),Stockholm, Sweden; Departments of Anaesthesiology andPain Therapy (Dr Cox) and Surgery and NUTRIM (Drsvon Meyenfeldt and Dejong), Maastricht University Medi-cal Centre, Maastricht, the Netherlands; Department of

Clinical and Surgical Sciences, Royal Infirmary of Edin-burgh, Edinburgh, Scotland (Drs Hendry and Fearon);Department of Anaesthesiology and Intensive Care Medi-cine, Campus Charite Mitte and Campus Virchow-Klinikum, Charite Universitaetsmedizin Berlin, Berlin,Germany (Dr Spies); and Division of Gastrointestinal Sur-gery, Nottingham Digestive Diseases Centre BiomedicalResearch Unit, Nottingham University Hospitals, Queen’sMedical Centre, Nottingham, England (Dr Lobo).Correspondence: Kristoffer Lassen, MD, PhD, Depart-ment of Gastrointestinal Surgery, University HospitalNorthern Norway, 9038 Tromsø, Norway ([email protected]).Author Contributions: Study concept and design: Las-sen, Soop, Nygren, von Meyenfeldt, Fearon, Revhaug,Ljungqvist, Lobo, and Dejong. Acquisition of data: Las-sen, Soop, Cox, Hendry, von Meyenfeldt, Norderval, andDejong. Analysis and interpretation of data: Lassen, Nygren,Hendry, Spies, Fearon, Norderval, Ljungqvist, and De-jong. Drafting of the manuscript: Lassen, Soop, Nygren,Cox, Hendry, Fearon, Lobo, and Dejong. Critical revi-sion of the manuscript for important intellectual content: Las-sen, Soop, Spies, von Meyenfeldt, Fearon, Revhaug, Nor-derval, 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: Las-sen, Soop, Nygren, Hendry, von Meyenfeldt, Revhaug,and Dejong.Enhanced Recovery After Surgery (ERAS) Group Mem-bers: Kristoffer Lassen, MD, PhD, Arthur Revhaug, MD,PhD, Stig Norderval, MD, PhD, University Hospital North-ern Norway, Tromsø, Norway; Mattias Soop, MD, PhD,University of Auckland, Grafton, Auckland, New Zea-land; Jonas Nygren, MD, PhD, Jonathan Hausel, MD, Er-sta Hospital, Stockholm, Sweden; P. Boris W. Cox, MD,Maarten F. von Meyenfeldt, MD, PhD, Cornelis H. C. De-jong, MD, PhD, Jose Maessen, BSc, Ronald M. van Dam,MD, Maastricht University Medical Centre, Maastricht,the Netherlands; Paul O. Hendry, MBChB, MRCS, Ken-neth C. H. Fearon, MD, FRCS, Royal Infirmary of Edin-burgh, Edinburgh, Scotland; Claudia Spies, MD, PhD,Charite Universitaetsmedizin Berlin, Berlin, Germany; OlleLjungqvist, MD, PhD, Karolinska University HospitalHuddinge, Stockholm, Sweden; Dileep N. Lobo, DM,FRCS, Nottingham Digestive Diseases Centre Biomedi-cal Research Unit, Nottingham University Hospitals,Queen’s Medical Centre, Nottingham, England; RobinKennedy, MD, St Mark’s Hospital, London, England.Financial Disclosure: Dr Ljungqvist is the owner ofa patent for a preoperative carbohydrate-rich drinklicensed to Danone/Nutricia, which produces and mar-kets a drink based on this patent.Funding/Support: This work was supported by Frese-nius Kabi, which has been sponsoring the ERAS Groupwith an unrestricted grant since 2006.Role of the Sponsor: Fresenius Kabi (or any other com-mercial company) has not participated in the researchwork, the discussions, the writing of the manuscript, orthe decision to publish the work.




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aagbi enhanced recovery seminar april 2010

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