ERAS

[acidbase1]

Anyone who’s used “these protocols”, do you feel theyre benefical? I used ketamine, lidocaine and precedex infusions during residency with the various adjuncts and never really appreciated a huge difference. Thoughts?

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[anbuitachi]

Anyone who’s used this protocol, do you feel it’s benefical? I used ketamine, lidocaine and precedex infusions during residency with the various adjuncts and never really appreciated a huge difference. Thoughts?

the difference is supposed to be for after surgery. are you checking up on them until discharge?

we switched to ERAS ~ a year ago and our department is still collecting data. obviously theres already data out supporting ERAS but i guess we want internal data too

 

[caveat87]

We have several ERAS pathways at my training institution. Few things i/we have noticed
-there does appear to be some reduction length of stay (especially in discussion with surgeons and looking at available data) in certain service lines but we are still collecting data
-Our surgery colleagues have noticed several of patients receiving goal directed fluid therapy have developed AKI on POD1 and POD2 (even if they were kept at the recommended MAP goal). How significant this is we don't know although AKI is an independent predictor of mortality in several disease states. However, maybe this is better than a prolonged ileus due to over-rescuscitation?
-The ketamine drip if left on too long (close to emergence) can lead to some big time PACU delirium or failure to follow commands which prolongs PACU recovery time.

 

[anbuitachi]

We have several ERAS pathways at my training institution. Few things i/we have noticed
-there does appear to be some reduction length of stay (especially in discussion with surgeons and looking at available data) in certain service lines but we are still collecting data
-Our surgery colleagues have noticed several of patients receiving goal directed fluid therapy have developed AKI on POD1 and POD2 (even if they were kept at the recommended MAP goal). How significant this is we don't know although AKI is an independent predictor of mortality in several disease states. However, maybe this is better than a prolonged ileus due to over-rescuscitation?
-The ketamine drip if left on too long (close to emergence) can lead to some big time PACU delirium or failure to follow commands which prolongs PACU recovery time.

i think its too early to assume AKI is due to less fluids? unless you have the renal studies to back it up

 

[nimbus]

-Our surgery colleagues have noticed several of patients receiving goal directed fluid therapy have developed AKI on POD1 and POD2 (even if they were kept at the recommended MAP goal). How significant this is we don't know although AKI is an independent predictor of mortality in several disease states. However, maybe this is better than a prolonged ileus due to over-rescuscitation?
.

My apologies about the tangent, but what is the MAP goal and how are you achieving this?

 

[Aether2000]

It appears there are many ERAS protocols during anesthesia that seem to vary institution to institution, with no real standards. Outcome studies from ERAS anesthesia protocols indeed often show little difference between non-ERAS from measurable anesthesia outcomes but discharge early seems to be the most consistent. Several studies have shown no significant improvement in post operative pain or opioid use in-hospital. Most disturbing is some ERAS publications never outline what their protocol actually is anywhere in the publication.

 

[woopedazz]

Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery NEJM
Published yesterday: ERAS goal-directed/restrictive fluids found to be non-superior to liberal application of fluids... and associated with high instances of AKI.

 

[anbuitachi]

It appears there are many ERAS protocols during anesthesia that seem to vary institution to institution, with no real standards. Outcome studies from ERAS anesthesia protocols indeed often show little difference between non-ERAS from measurable anesthesia outcomes but discharge early seems to be the most consistent. Several studies have shown no significant improvement in post operative pain or opioid use in-hospital. Most disturbing is some ERAS publications never outline what their protocol actually is anywhere in the publication.

agree it varies. our eras doesn't include post op infusions for pain such as ketamine or lidocaine. it pretty much only includes iv tylenol. and pacu nurses also love to give opioids to begin with so i dont know how much opioid use actually change post op

 

[GlowInTheDark]

Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery NEJM
Published yesterday: ERAS goal-directed/restrictive fluids found to be non-superior to liberal application of fluids... and associated with high instances of AKI.

I’ve been waiting for this

 

[caveat87]

For most of the ERAS pathways, we use a MAP goal of >65 or within 20% of the patient's baseline blood pressure. A masimo pulse ox device is used to obtain a PVI to assess fluid responsiveness which determines if a pressor (ephedrine or NE bolus) or fluid bolus (usually 500ml crystalloid) should be administered. I believe we can also use the PPV to estimate fluid responsiveness in cases where blood pressure is measured with an arterial catheter. Naturally there are certain operative conditions (ie: open chest, arrhythmia, etc.) which make these features difficulty to interpret.

 

[Urzuz]

Anyone who’s used this protocol, do you feel it’s benefical? I used ketamine, lidocaine and precedex infusions during residency with the various adjuncts and never really appreciated a huge difference. Thoughts?

"ERAS" is not a singular protocol and there are substantial differences between institutions, types of surgery, etc. What specific surgery are you talking about?

And yes, for the most part ERAS pathways are beneficial, probably in the same way ARDSnet was helpful in preventing people who trained decades ago from harming their patients with outdated medicine/techniques.

 

[acidbase1]

"ERAS" is not a singular protocol and there are substantial differences between institutions, types of surgery, etc. What specific surgery are you talking about?

And yes, for the most part ERAS pathways are beneficial, probably in the same way ARDSnet was helpful in preventing people who trained decades ago from harming their patients with outdated medicine/techniques.

I was more speaking in general. Everyone knows there are variations. Quit being so clever

 

[pgg]

Quit being so clever

Quit being so vague. 🙂

 

[Psai]

We have several ERAS pathways at my training institution. Few things i/we have noticed
-there does appear to be some reduction length of stay (especially in discussion with surgeons and looking at available data) in certain service lines but we are still collecting data
-Our surgery colleagues have noticed several of patients receiving goal directed fluid therapy have developed AKI on POD1 and POD2 (even if they were kept at the recommended MAP goal). How significant this is we don't know although AKI is an independent predictor of mortality in several disease states. However, maybe this is better than a prolonged ileus due to over-rescuscitation?
-The ketamine drip if left on too long (close to emergence) can lead to some big time PACU delirium or failure to follow commands which prolongs PACU recovery time.

I think it's better to stop the ketamine about an hour prior to finishing a case to prevent them from weirding out the pacu nurses.

Goal directed therapy is a sham. We don't have good methods to determine fluid status.

 

[nimbus]

I think it's better to stop the ketamine about an hour prior to finishing a case to prevent them from weirding out the pacu nurses.

Goal directed therapy is a sham. We don't have good methods to determine fluid status.

Except TEE.

 

[Urzuz]

I was more speaking in general. Everyone knows there are variations. Quit being so clever

The way you phrased your initial question made it seem like you didn't know there were variations, since you referred to it as "this protocol." ERAS protocols are very different between specialty and institution, so you have to be more specific...otherwise you're asking people to compare apples and oranges. Not all ERAS protocols, for instance, have ketamine, lidocaine, and Precedex infusions associated with them.

 

[acidbase1]

The way you phrased your initial question made it seem like you didn't know there were variations, since you referred to it as "this protocol." ERAS protocols are very different between specialty and institution, so you have to be more specific...otherwise you're asking people to compare apples and oranges. Not all ERAS protocols, for instance, have ketamine, lidocaine, and Precedex infusions associated with them.

Still being clever

 

[Urzuz]

Still being clever

It seems like you could use a little more cleverness then. 🙂

But for real, all I was asking was whether you wanted information about a specific surgical type.

"ERAS" is not a singular protocol and there are substantial differences between institutions, types of surgery, etc. What specific surgery are you talking about?

I don't know what your issue is but apparently I bruised your internet ego with that "inflammatory statement" so you decided to start talking about me instead, when I was providing information for a question that I thought you asked. I guess my presence won't provide anything to this discussion so I'll stop posting on this thread, which is sad because I actually have done plenty of research on ERAS protocols, specifically for colorectal surgery (the surgery specialty with the most data out there for ERAS) and it would have been an interesting discussion.

I'll leave you all with a practice guideline that was published jointly with ASCRS regarding ERAS for colorectal surgery: https://www.fascrs.org/sites/defaul...actice_guidelines_for_enhanced_recovery.3.pdf

I do appreciate the edit to the original post though.

 

[acidbase1]

It seems like you could use a little more cleverness then. 🙂

But for real, all I was asking was whether you wanted information about a specific surgical type.



I don't know what your issue is but apparently I bruised your internet ego with that "inflammatory statement" so you decided to start talking about me instead, when I was providing information for a question that I thought you asked. I guess my presence won't provide anything to this discussion so I'll stop posting on this thread, which is sad because I actually have done plenty of research on ERAS protocols, specifically for colorectal surgery (the surgery specialty with the most data out there for ERAS) and it would have been an interesting discussion.

I'll leave you all with a practice guideline that was published jointly with ASCRS regarding ERAS for colorectal surgery: https://www.fascrs.org/sites/defaul...actice_guidelines_for_enhanced_recovery.3.pdf

I do appreciate the edit to the original post though.

Just messing with you man. Thank you for the info

 

[Psai]

Still being clever

Hey, don't come in here with a question and try to talk down to the people helping you.

 

[acidbase1]

Hey, don't come in here with a question and try to talk down to the people helping you.

Stop whining

 

[BobLoblaw78]

Anyone who’s used “these protocols”, do you feel theyre benefical? I used ketamine, lidocaine and precedex infusions during residency with the various adjuncts and never really appreciated a huge difference. Thoughts?

I have used the lidocaine and ketamine. I don't believe that they cause harm and maybe help, although not immediately evident. I know there are only a few that show problems with ketamine, but they are in the vast minority. I think most things that limit opioids intraoperatively are going to be beneficial, especially in lower doses. I am excited to try precedex again, but it has been about a decade since I have used it and we still don't have it where I work. Haldol seems to be doing a good job limiting PONV/PDNV that is readily apparent.

Has anyone experienced or read about other recent trends that are promising? What about decadron in blocks? I don't like the variability but have started trying it again.

 

[Aether2000]

I use decadron in my blocks but with our ERAS protocols, many of the surgeons give decadron IV, therefore the overall dosage would be too high if decadron were added to my blocks. Instead, I use clonidine and epi added to the blocks.

 

[Psai]

I have used the lidocaine and ketamine. I don't believe that they cause harm and maybe help, although not immediately evident. I know there are only a few that show problems with ketamine, but they are in the vast minority. I think most things that limit opioids intraoperatively are going to be beneficial, especially in lower doses. I am excited to try precedex again, but it has been about a decade since I have used it and we still don't have it where I work. Haldol seems to be doing a good job limiting PONV/PDNV that is readily apparent.

Has anyone experienced or read about other recent trends that are promising? What about decadron in blocks? I don't like the variability but have started trying it again.

Some of our people use it in a low infusion during the case while others give a bolus at the end like they were doing peds. It seems to help with a smooth emergence.

 

[PonyUp]

We have several pathways at my shop. Specifically Pectus kids and congenital cardiac surgery kids. Although neither has anything to do with fluid management [paravertebral catheters and multimodal anesthesia for the pectus kids, opioid caudals and methadone, come off pump on remi/dex for the non-complex congenital cardiac surgery kids]. I think the term ERAS gets thrown around a lot and then applied to everything these days, sometimes to justify particular anesthetic managment [and not the other way around].

 

[aneftp]

I think it's better to stop the ketamine about an hour prior to finishing a case to prevent them from weirding out the pacu nurses.

Goal directed therapy is a sham. We don't have good methods to determine fluid status.

Clearsite? To determine fluid status for “goal directed therapy”