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ERAS (Enhanced Recovery after Surgery) Protocols

Discussion in 'Anesthesiology' started by hooride, Sep 5, 2014.

  1. hooride

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    Anyone have experience with these, positive or negative? I've posted Duke's colorectal protocol below (Anesth Analg. 2014 May;118(5):1052-61) - not sure if they're still using Voluven since the FDA warning came out:

    --------------------------------------------------------------------------------------------------
    DUKE Anesthesia Colorectal Enhanced Recovery Guidelines Intervention Protocol

    Thoracic epidural
    T8-T12 region
    5000 U subcutaneous heparin can be given after placement
    Hydromorphone 0.4 to 0.6 mg before induction of anesthesia
    Lidocaine 2% bolus at least 10 min preincision (40–100 mg)
    Run infusion of 0.25% bupivacaine throughout case (3–6 mL/h)
    No intraoperative IV opioids after induction without discussion with the attending anesthesiologist
    Switch to bupivacaine 0.125%/hydromorphone 10 mcg/mL in epidural pump before leaving for PACU at end of case.
    •Settings: infusion 4 to 6 mL/h; 2 mL bolus every 30 min

    Goal-directed fluid therapy
    1000 mL LR bolus–commenced in preoperative holding area to be infused during induction and then finished.
    LR infusion for rest of case based on lean body weight (max 80 kg)
    •5 mL/kg/h for open cases using an infusion pump (max 400 mL/h)
    •3 mL/kg/h for laparoscopic cases using an infusion pump (max 240 mL/h)
    Esophageal doppler placed after induction.
    Record initial stroke volume (SV)
    After incision (after pneumoperitoneum for laparoscopic cases) give a 250 mL colloid bolus over <15 min (suggest five 50 mL syringe pushes).
    •If SV increases by >10%, repeat bolus.
    •If SV increases by <10%, patient does not require a further bolus.
    •Record peak value achieved.
    •If still hypotensive, consider phenylephrine infusion.
    •Give a further colloid bolus when SV drops 10% from peak value.
    •Repeat cycle.
    Max Voluven dose 50 mL/kg
    Reduce LR to 2mL/kg/h before transfer to PACU.
     
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  3. hooride

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    UVA protocol attached. Different from Duke: duramorph spinals instead of low thoracic epidurals, PVI instead of esophageal doppler. Thoughts?
     

    Attached Files:

  4. BLADEMDA

    BLADEMDA ASA Member
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    In summary, providing the best care remains as valid as ever. GDT is safe22; in the greatest-risk patients, it can bring both clinical and economical benefits.28 We do not think that this is the end of GDT. All therapy should be goal directed; the challenge is how to set the right goals. GDT may now not show the strong difference in outcome observed in the first studies, but it does not mean that we should get rid of it. It may only mean that just focusing solely on hemodynamics is too simplistic an approach. GDT has to be considered mainly as part of a bundle of treatments that encompasses all facets of care for these patients.29 New bundles for the care of surgical patients will have to take this into account and are largely awaited.


    Nevertheless, this study adds to more recent ones showing no benefit for GDT.16–18
     
  5. BLADEMDA

    BLADEMDA ASA Member
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    Anesth Analg. 2014 Sep;119(3):579-87. doi: 10.1213/ANE.0000000000000295.
    Perioperative Goal-Directed Hemodynamic Optimization Using Noninvasive Cardiac Output Monitoring in Major Abdominal Surgery: A Prospective, Randomized, Multicenter, Pragmatic Trial: POEMAS Study (PeriOperative goal-directed thErapy in Major Abdominal Surgery).
    Pestaña D1, Espinosa E, Eden A, Nájera D, Collar L, Aldecoa C, Higuera E, Escribano S, Bystritski D, Pascual J, Fernández-Garijo P, de Prada B, Muriel A, Pizov R.
    Author information

    Abstract
    BACKGROUND:
    In this study, our objective was to determine whether a perioperative hemodynamic protocol based on noninvasive cardiac output monitoring decreases the incidence of postoperative complications and hospital length of stay in major abdominal surgery patients requiring intensive care unit admission. Secondary objectives were the time to peristalsis recovery and the incidence of wound infection, anastomotic leaks, and mortality.

    METHODS:
    A randomized clinical trial was conducted in 6 tertiary hospitals. One hundred forty-two adult patients scheduled for open colorectal surgery, gastrectomy, or small bowel resection were enrolled. A hemodynamic protocol including fluid administration and vasoactive drugs based on arterial blood pressure, cardiac index, and stroke volume response was compared with standard practice. Patients were followed until hospital discharge (determined by a surgeon blinded to the study) or death. In contrast to previous studies, we designed a pragmatic trial (as opposed to explanatory trials) to mimic real practice and obtain maximal external validity for the study.

    RESULTS:
    Fluid administration was similar except for the number of colloid boluses (2.4 ± 1.8 [treated] vs 1.3 ± 1.4 [control]; P < 0.001) and packed red blood cell units (0.6 ± 1.3 [treated] vs 0.2 ± 0.6 [control]; P = 0.019). Dobutamine was used in 25% (intraoperatively) and 19.4% (postoperatively) of the treated patients versus 1.4% and 0% in the control group (P < 0.001). We have observed a reduction in reoperations in the treated group (5.6% vs 15.7%; P = 0.049). However, no significant differences were observed in overall complications (40% vs 41%; relative risk 0.99 [0.67-1.44]; P = 0.397), length of stay (11.5 [8-15] vs 10.5 [8-16]; P = 0.874), time to first flatus (62 hours [40-76] vs 72 hours [48-96]; P = 0.180), wound infection (7 vs 14; P = 0.085), anastomotic leaks (2 vs 5; P = 0.23), or mortality (4.2% vs 5.7%; P = 0.67).

    CONCLUSIONS:
    The results of our pragmatic study indicate that a perioperative hemodynamic protocol guided by a noninvasive cardiac output monitor was not associated with a decrease in the incidence of overall complications or length of stay in major abdominal surgery.
     
  6. BLADEMDA

    BLADEMDA ASA Member
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    My patient population is elderly. There is NO WAY I'm using large doses of ketamine in that subgroup. Instead, I limit my exposure to all anesthetic agents (vapor, narcotics, etc) by placing a preop TAP block as described by Hebbard. If the patient is having a massive open procedure I add a little buprenorphine to my block (30 mics per side) as this provides 24 hours of analgesia without the need to do an epidural or sab. Patients have low pain scores (0-2) and require almost no narcotics in pacu. Hence, the ketamine, IV lidocaine, Mg++, etc is all voodoo.

    You boys need to enter the 21st Century and provide PAIN CONTROL with enhanced patient safety. As for the GDT I'm fine with the Non invasive monitoring for the ASA 3 and ASA 4 Group along with BIS to minimize exposure to the volatile agents. I instruct my CRNAs to use the C.I./SVV. SVI as a guide to basic fluid management but not overload the patient (e.g. the goal is adequate fluid replacement).

    Less is more and once you see the brilliance of the Tap/Subcostal TAP by Hebbard combined with low dose Buprenorphine for open procedures you won't go back to the late 1990s. Leave the SAB for your total joint patients.

    Blade
     
  7. BLADEMDA

    BLADEMDA ASA Member
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  8. BLADEMDA

    BLADEMDA ASA Member
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  9. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    The thickness of BS in this thread is beyond belief!
    Place an epidural... put the guy to sleep and use epidural pain management... it's not rocket science although they tend to think so at Duke!
     
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  10. WholeLottaGame7

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    Switched to 5% albumin instead of voluven. Also, the esophageal doppler was a pain in the ass so there was a low threshhold to put in an a-line and use PPV for fluid management instead.
     
  11. BLADEMDA

    BLADEMDA ASA Member
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    I doubt there is any good evidence for the use of Albumin over LR or Normosol in this situation provided preop Albumin level is normal.
     
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  12. BLADEMDA

    BLADEMDA ASA Member
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    Arch Surg. 2010 Apr;145(4):371-6; discussion 376. doi: 10.1001/archsurg.2010.40.
    Risk factors for anastomotic leak following colorectal surgery: a case-control study.
    Telem DA1, Chin EH, Nguyen SQ, Divino CM.
    Author information

    Abstract
    OBJECTIVE:
    To assess anastomotic leak (AL) risk factors in a large patient series.

    DESIGN:
    Case-control study.

    SETTING:
    The Mount Sinai Hospital.

    PATIENTS:
    Ninety patients with AL following colorectal resection and 180 patients who underwent uncomplicated procedures.

    MAIN OUTCOME MEASURES:
    Risk factors associated with development of AL.

    RESULTS:
    The AL rate was 2.6%. Five risk factors for AL were identified: (1) preoperative albumin level lower than 3.5 g/dL (odds ratio [OR] 2.8; 95% confidence interval [CI], 1.3-5.1) (P = .03); (2) operative time of 200 minutes or longer (OR, 3.4; 95% CI, 2.0-5.8) (P = .01); (3) intraoperative blood loss of 200 mL or more (OR, 3.1; 95% CI, 1.9-5.3) (P = .01); (4) intraoperative transfusion requirement (OR, 2.3; 95% CI, 1.2-4.5) (P = .02); and (5) histologic specimen margin involvement in disease process in patients with inflammatory bowel disease (IBD) (OR, 2.9; 95% CI, 1.4-6.1) (P = .01). Patients with all 3 intraoperative risk factors had an OR of 22.1; 95% CI, 2.8-175.4 (P < .001) for development of AL.

    CONCLUSIONS:
    Histologic resection margin involvement in disease process in patients with IBD, preoperative albumin levels lower than 3.5 g/dL, intraoperative blood loss of 200 mL or more, operative time of 200 minutes or more, and/or intraoperative transfusion requirement increased AL risk. Enteral nutritional optimization prior to elective surgery is essential. Proximal diversion should be considered for patients with all 3 intraoperative risk factors because they are at high risk for AL.
     
  13. BLADEMDA

    BLADEMDA ASA Member
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    1. Some patients may have been taking anticoagulants like Plavix (off 5 days) or Xarelto or Pradaxa or Eliquis (not off them long enough)
    2. Surgeons want to start anticoagulation on POD 2 (Epidural must be D/C'd)
    3. Local anesthetics (even dilute) may cause hypotension in an elderly patient population
    4. Technically more difficult to do a High Epidural or Low thoracic Epidural vs a BD Tap block in the elderly
    5. Lap assisted or Robotic Colorectal surgery patients benefit from BD TAP blocks and don't need an Epidural
    6. No post op rounds are necessary or getting calls at midnight from the RN about your Epidural

    BD Tap Blocks are the solution to the problem.
     
  14. BLADEMDA

    BLADEMDA ASA Member
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    http://www.ncbi.nlm.nih.gov/pubmed/23810575


    http://www.ncbi.nlm.nih.gov/pubmed/23355160


    http://www.ncbi.nlm.nih.gov/pubmed/24641640


    http://www.ncbi.nlm.nih.gov/pubmed/23808506


    Effective, safe pain control which equals that of an epidural without the worries about postop anticoagualtion (or even preop anticoagulation).

    Success rate was 28/30 (93%) in the transversus group vs 27/31 (87%) in the epidural group. Continuous transversus abdominis plane infusion was non-inferior to epidural infusion in providing analgesia after laparoscopic colorectal surgery.
     
  15. BuzzPhreed

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    I hope they aren't using Voluven anymore. No one should use pentastarches anymore. Period.

    As far as goal-directed therapy, I agree with Planktonmd. This is WAY overthinking. If it's a big case and they have an a-line, look at the pulse wave variation and see if they have a respiratory oscillation. Give some fluid and see if it gets better. Monitor UOP. Keep it simple.

    A good epidural dosed appropriately and 0.7 MAC of anesthetic. The rest is Rube Goldbergesque.
     
  16. dhb

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    No one should have been using pentastarches to begin with, never understood those who did.
     
  17. cowbydoc

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    Awesome Blade! We have started to do the ERAS protocol at our institutions and I have thought that although well intentioned it is cumbersome and inefficient. We currently do not use buprenorphine in our TAP blocks but I will now look in to it. Epidurals are great but are also a huge hassle to manage and come with rare but serious complications. There is no silver bullet to any problem usually but this sounds like a better alternative.
     
  18. caligas

    caligas ASA Member
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    Bumping.

    Our hospital is full court press on this ERAS stuff. They are measuring our individual compliance (fluid restriction, antinausea meds....)

    Any similar experiences?
     
  19. dr doze

    dr doze To be able to forget means to sanity
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    :rofl:Gotta build that professorship somehow.
     
  20. fakin' the funk

    fakin' the funk ASA Member
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    We do ERAS for colorectal. We don't have individual compliance tracking. But 99% of ERAS is common sense. PO fluids until 2h before surgery, PONV prophylaxis, minimize opioids by giving non-opioids, avoid fluid excess, epidurals for planned open cases.

    The dependence / reliance on fluid responsiveness monitors, however, is pretty stupid IMO. I think they are more useful for telling you when NOT to give fluids (90-95% of intraoperative hypotension -- SVR mediated), i.e., when the PVI or PPV is < 15%. Once it gets above 13-15% or so it's clinically obvious that the patient is hypovolemic anyway.
     
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  21. BLADEMDA

    BLADEMDA ASA Member
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    Clinical Anesthesiology
    JANUARY 12, 2016
    Perioperative ERAS Protocols Reduce Pancreatic Patients’ Length of Stay

    [​IMG]
    San Diego—Implementation of enhanced recovery after surgery (ERAS) protocols for pancreatic surgery decreased hospital length of stay (LOS), a study concluded, which ultimately improves quality of care, accelerates recovery, improves outcomes and optimizes utilization of health care resources.

    “Enhanced recovery clinical pathways are really a paradigm shift that serve to evaluate our traditional practices and make evidence-based recommendations for improvement,” said Lavinia M. Kolarczyk, MD, assistant professor of anesthesiology at The University of North Carolina at Chapel Hill School of Medicine. “Nevertheless, the pathways themselves are not novel. The innovative aspect of enhanced recovery is learning how to work together in multidisciplinary teams to implement these best-practice guidelines.

    “Ultimately, ERAS serves as the vehicle to promote quality improvement research; break down practice silos between anesthesiologists, surgeons and perioperative nurses; and really challenge why we do what we do every day.”
     
  22. urge

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    My hosp is also pushing for an ERAS protocol. I love it when they track the process rather than the outcome. They do the same here.
     
  23. Hoya11

    Hoya11 Senior Member
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    I have not found this to be the case with PPV and have sometimes been surprised that they are either euvolemic when I thought they were dry, or still dry despite what i thought was adequate resuscitation.

    What is the downside to using PPV vs clinical judgement? I can see if the patient is blue but I look at the pulse ox for a more precise measurement..

    I wouldnt put an aline in solely for this purpose though, if thats what you mean..
     
  24. WholeLottaGame7

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    I'm kind of drifting farther and farther away from PPV, also. It's only validated under very specific circumstances, which oftentimes don't apply. At best, I find it's about as useful as CVP (i.e., a trend monitor). I don't think it's any more advantageous than choosing some low-dose pressor (phenyl or NE) rate to counteract the drop in SVR, keeping your anesthetic level constant, and then trending BP. If I'm really worried about volume status, I'll check an ABG.

    FWIW, I don't think it's just a process they're concerned about. Both hospitals I've been at that implemented it have seen real decreases in hospital LOS and other measures. I think a lot of stuff that seems common sense to most of us on this board is not so common at all. I've seen some weird a** anesthetic management in my short time, so while I'm not at all about cookbook medicine, I think some degree of standardization (or for some people just education on recent literature/advances) is beneficial.
     
  25. criticalelement

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    Goal directed fluid therapy as opposed to non goal directed fluid therapy
     
  26. ranvier

    ranvier I can't anesthetize a rumor.
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    What is an acceptable creatinine bump on pod#1? How tight are the insulin control goals? Most importantly, what kind and orientation of eye tape?!
     
  27. fakin' the funk

    fakin' the funk ASA Member
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    What I meant by "dependence / reliance on PVI / PPV" was the NSQIP / ERAS people's leaning on these fluid responsiveness monitors as a quality measure of "avoiding fluid excess." The measures are met if you USE one of these monitors -- you can still give 5L of LR to a 50kg patient in a 3hour case and get a gold star if you use the monitor.

    There's value to be had in PVI / PPV. I think of it like a "nudge" away from giving IVF when a little arteriolar and venular tone is the correct option.
     
  28. fakin' the funk

    fakin' the funk ASA Member
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    A lot of the benefit of ERAS is the postop stuff.

    The expectation that patient will be out of bed on POD#0 and have their precious, precious dilaudid PCA taken away morning of POD#1, if they had one at all. De-Foleying. Early diet. Maintaining "homeostasis" as much as possible through the various perioperative insults. Our intraoperative part is just a slice. A lot of it *IS* common sense, and not flavor-of-the-month research dogma, which is what I like about ERAS.

    Of course, I could end up eating my words in a couple years once the pendulum swings back.:eek:
     
  29. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    LAW #13: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.
     
  30. caligas

    caligas ASA Member
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    Or:

    "Don't just do something, stand there!"
     
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  31. urge

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    It is debatable. A commonly held practice is to place them parallel to the wrinkle lines. However, it has been suggested that placing them in the direction your chakras emit energy might be more beneficial. Randomized trials are definitely needed.
     
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  32. Planktonmd

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    I can't believe you are recommending the shakra direction method! It could interfere with the energy emitted from your hypnotic crystals that you place near the patient's head!
     
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