ERAS for Colorectal Surgery

Objectives
• To briefly discuss ERAS and its background
• To discuss the guidelines for perioperative care in colorectal surgery as recommended
by ERAS Society and the different phases of the pathway, namely:
 Preadmission
 Preoperative
 Intraoperative
 Postoperative
ERAS
• Enhanced recovery after surgery
• Patient centered, evidence-based, multidisciplinary team developed pathways for
surgical specialty
• Pathways form a continuum as the patient moves from home through preadmission,
preoperative, intraoperative, and postoperative phases of surgery
• Goals:
 Reduce patient’s surgical stress response
 Optimize physiologic function
 Facilitate recovery
Background
• Novel perioperative regimen for patients following colon surgery described in 1995 by
Professor Kehlet using early oral nutrition, early mobilization, and epidural analgesia
• ERAS study group was founded in 2001 to expand on the ideas by Professor Kehlet and
the group desired to create a consensus on best practices
ERAS in Colorectal Surgery
• Initial development of ERAS pathways occurred in colon surgery patients
• Early studies demonstrated principles of:
 Early mobilization
 Early feeding
 Optimized IV fluid administration

• Results
 Tolerating diet sooner
 Faster return of bowel function
 Earlier discharge

• Complications
 UTI, ileus, ,cardiopulmonary complications
ERAS in Colorectal Surgery
• Adherence is inversely related to length of hospital stay postoperatively
• If compliance is lower, length of stay is longer
• Predictors of shorter stay
 Preop carbohydrate loading
 No NGT
 Early removal of urinary catheter
 Use of nonopioid analgesia

• Predictors of longer stay

 Pathologic diagnosis
 Intraoperative complications
 High blood loss
 Surgery length
 Persistent use of IV fluids
 Reinsertion of urinary catheter
 Poor pain control
PREADMISSION

PREOPERATIVE

INTRAOPERATIVE

POSTOPERATIVE
 1. Preadmission information, education, and counselling
2. Preoperative optimization

PREADMISSION 3. Prerehabilitation
4. Preoperative nutritional care
5. Management of anemia

6. Prevention of nausea and vomiting

7. Pre-anesthetic medication
8. Antimicrobial prophylaxis and skin preparation
PREOPERATIVE 9. Bowel preparation
10. Preoperative fluid and electrolyte therapy
11. Preoperative fasting and carbohydrate loading
12. Standard anesthetic protocol
13. Intraoperative fluid and electrolyte therapy

INTRAOPERATIVE 14. Preventing intraoperative hypothermia

15. Surgical access
16. Drainage of the peritoneal cavity and pelvis
17. Nasogastric intubation
18. Postoperative analgesia
19. Thromboprophylaxis
20. Postoperative fluid and electrolyte therapy

POSTOPERATIVE 21. Urinary drainage

22. Prevention of postoperative ileus
23. Postoperative glycemic control
24. Postoperative nutritional care
25. Early mobilization
Preadmission
_________________________________________________________c
1. Preadmission Information, Education,
and Counselling
• Goals:
 Reduce anesthesia- and surgery-related anxiety and subsequent pain
 Improve patient’s preparedness, satisfaction, and overall surgical experience

• Positive impact on LOS and postoperative outcomes have been reported

• Multidisciplinary team
 Preoperative Optimization
RISK ASSESSMENT SMOKING CESSATION AVOIDING ALCOHOL INTAKE

• General preoperative medical • Smokers have increased risk of • Alcohol abuse increases postop
assessment and optimization is intraop and postop complications morbidity
important
• Interventions for smoking • More than 2 units of alcohol per
• Specific preoperative risk cessation day increases risk for postop
assessment scores have low  Pharmacologic (e.g. nicotine infection but not mortality
level evidence replacement therapy)
 Behavioral (e.g. counselling) • 4 weeks abstinence recommended

• 4-8 weeks abstinence  reduce

respiratory and wound-heling
complications
 Shorter periods may still yield
benefits
Prerehabilitation
• A process in the continuum of care that occurs between the time of diagnosis and the
beginning of acute treatment
• Physical, nutritional, and psychological assessments that establish a baseline functional
level, identify impairments, and provide interventions that promote physical and
psychological health
• Less fit patients more likely to benefit
 Addition of physical fitness and activity to preop elderly patients improved mortality, discharge
to home, and length of stay

• Further research required before it is considered a mandatory item in ERAS

Preoperative Nutritional Care
• Preop malnutrition
 Increased postop morbidity and mortality
 Poor oncologic outcomes in surgery for GI cancers

• Currently no consensus how to assess preop nutritional status accurately

 Nutritional risk screening score (NRS 2002)
 Subjective global assessment (SGA)
 Patient generated subjective global assessment (PG-SGA)
 Malnutrition universal screening tool (MUST)

• For malnourished patients, oral nutritional supplementation has the best effect if started
7-10 days preoperatively
 Reduction in the prevalence of infectious complications and anastomotic leaks
Management of Anemia
• Common in patients for surgery and increases all-cause morbidity
• Causes:
 Acute or chronic blood loss
 Vitamin B12 or folate deficiency
 Anemia of chronic disease

• Hemoglobin targets
 60-100 g/L – individualized depending on comorbidities and type of surgery
 >80 g/L – patients with cardiac, renal and pulmonary problems

• Treatment:
 Oral: cheap, easily administered, may be poorly tolerated
 IV: Low risk of adverse reactions, more effective than oral in restoring hemoglobin
concentrations
Preoperative
Prevention of Nausea and Vomiting
• Postoperative nausea and vomiting (PONV) affects 30-50% of surgical patients
• Risk factors
 Female sex
 Past history of PONV or motion sickness
 Nonsmokers
 Duration of surgery >60 minutes
 Postop opioid treatment is planned

• Scoring systems – Koivuranta score, Apfel score

• PONV may result in:
 Dehydration
 Delayed return of adequate nutritional intake
 Placement of NGT
 Increased IV fluid administration
 Prolonged hospital stay
 Increased healthcare costs
Prevention of Nausea and Vomiting
• PONV prophylaxis should be considered in all patients
 1-2 risk factors  two antiemetics
 >2 risk factors  two to three antiemetics

• Multimodal administration of antiemetics reduces PONV further

• If nausea and vomiting still occur, salvage therapy using a different class of drugs from
those used for prophylaxis
• Antiemetics
 First line drugs: dopamine (D2) antagonists, serotonin antagonists, corticosteroids
 Second line drugs: antihistamines, anticholinergics
 Others: Gabapentin, pregabalin, neurokinin-1 receptor antagonist

• Alternative therapies
 Music therapy, aromatherapy, acupuncture, hypnosis and relaxation technique
Pre-anesthetic medication
• Psychological distress may increase perioperative analgesic requirements and
postoperative complication rates
• Patient education can reduce patient anxiety to an acceptable level without anxiolytic
medications
• Sedatives such as benzodiazepines should be avoided if possible before surgery,
especially for elderly patients
 Increased sensitivity to benzodiazepines  delirium, cognitive impairment, falls

• Opioid-sparing multimodal pre-anesthetic medication with combination paracetamol,

NSAIDS and gabapentanoids
 Decreased opioid-related adverse effects (nausea, vomiting, sedation, ileus, respiratory
depression
 Oral formulations  cost effective
 Timing is important
Antimicrobial Prophylaxis and Skin
Preparation
ANTIMICROBIAL PROPHYLAXIS
• IV antibiotic prophylaxis should be give 60 minutes before incision as a single dose
administration
• Patients receiving oral mechanical bowel preparation are also given oral antibiotics
• No recommendation for the use of oral antibiotic decontamination for patients having
no bowel preparation
Antimicrobial Prophylaxis and Skin
Preparation
SKIN PREPARATION
• Performed using chlorhexidine-alcohol based preparations
 Lower incidence of SSIs

• Insufficient evidence to support antiseptic showering, routine shaving and adhesive

incise sheets
 Routine hair removal before surgery does not reduce SSI but if necessary should be done using
clippers and not razors
Bowel Preparation
• Mechanical bowel prep alone with systemic antibiotic prophylaxis
 No clinical advantage
 Can cause dehydration and discomfort
 Should not be used routinely in colonic surgery
 May be used for rectal surgery
Preoperative Fluid and Electrolyte Therapy
• Patients should reach anesthetic room in as close a state of euvolemia as possible
• Fluid and electrolyte excesses and deficits should be corrected
Preoperative Fasting and Carbohydrate
Loading
• Allowed to eat up until 6 hours and take clear fluids including CHO drinks up until 2
hours before initiation of anesthesia
 Oral carbohydrates has been shown to attenuate catabolic response induced by overnight fasting
and surgery

• Patients with delayed gastric emptying and emergency patients should remain fasted
overnight or 6 hours before surgery
• CHO drinks not recommended for patients with diabetes
Intraoperative
Standard Anesthetic Protocol
ANESTHETIC AGENT AND CEREBRAL FUNCTION MONITORING
• Avoidance of benzodiazepines and use of short acting general anesthetic agents allow
rapid awakening with minimal residual effects
• Cerebral function monitoring using hi-spectral index with a target between 40 and 60
can reduce risk of awareness in high risk patients
 Avoid overdose of anesthesia in the elderly  reduce risk of postop delirium and cognitive
dysfunction
Standard Anesthetic Protocol
MUSCLE RELAXATION AND NEUROMUSCULAR MONITORING
• Neuromuscular monitoring should be standard of care
 Ideally with accelomyography

• Cumulative dosing of muscle relaxants increases the risk of postoperative pulmonary

complications
• Reversal of neuromuscular blockade
 Sugammadex – rocuronium, vecuronium
 Neostigmine
Intraoperative Fluid and Electrolyte
Therapy
• Goal is to maintain fluid homeostasis avoiding fluid excess and organ hypoperfusion
• A perioperative near-zero fluid balance approach should ne preferred
• Goal-directed fluid therapy should be adopted especially in high risk patients and in
patients undergoing surgery with large intravascular fluid loss
• Inotropes should be considered in patients with poor contractility
Preventing Intraoperative Hypothermia
• Reliable temperature monitoring should be undertaken in all colorectal surgical patients
• Actively warm patients to avoid inadvertent perioperative hypothermia
• Adverse effects
 Increased blood loss
 Vasoconstriction
 Increased afterload
 Myocardial ischemia
 Cardia arrhythmia
Surgical Access
• Minimally invasive approach
 Improved and more rapid recovery
 Reduced general complications
 Reduced wound-related complications including incisional hernia
 Fewer adhesions
 Enabler for successful administration of components of ERAS such as opioid sparing analgesia
Drainage of the peritoneal cavity and
pelvis
• Pelvic and peritoneal drain show no effect on clinical outcome and should not be used
routinely
Postoperative
Nasogastric Intubation
• Postoperative nasogastric tubes should not be used routinely
• NGT use actually delays return of gastrointestinal activity and increases pulmonary
complications
• If inserted during surgery, they should be removed before reversal of anesthesia
Postoperative analgesia
• Avoid opioids
• Apply multimodal analgesia in combination with spinal/epidural analgesia, when
indicated
Epidural blockade
• Thoracic epidural analgesia using low dose local anesthetic and opioids is
recommended in open colorectal surgery to minimize metabolic stress response and
provide analgesic postoperatively.
• In laparoscopic surgery, TEA can be used but not recommended over alternative
methods
Spinal Anesthesia/ Analgesia
• Spinal anesthesia with low dose opioids
 Good analgesic effects
 Transient stress-reducing effect
 Allows postoperative opiate sparing
 Patient mobilized sooner
 Less hypotension risk
Lidocaine Infusions
• Lidocaine infusions can reduce opiate consumption after surgery
• Dosing: 1.5 to 3 mg/kg/h
• Toxicity is related to plasma concentration and appears to be rare but postop monitoring
is important
 Continuous ECG monitoring
 Tinnitus, blurred vision, dizziness, tongue paresthesia, perioral tingling

 Reduction of postoperative ileus is unclear

Abdominal Wall Blocks
• Tranversus abdominis plane blocks reduce opioid consumption and improve recovery
• Provides analgesia below the umbilicus, subcostal and rectus blocks are adjuncts which
can cover the upper abdomen
Thromboprophylaxis
• Mechanical thromboprophylaxis by well-fitting compression stockings and/or
pneumatic compression until discharge
• Pharmacologic prophylaxis with LMWH once daily for 28 days after surgery
Postoperative fluid and electrolyte therapy
• Net “near-zero” fluid and electrolyte balance should be maintained
• Maintenance: hypotonic crystalloids should be used
• Replacement of losses: saline 0.9% and saline-based solutions should be avoided
 Hyperchloremic acidosis
 Interstitial fluid overload
 Impairment of renal hemodynamics
 Reduction in urinary water and sodium excretion
Urinary Drainage
• Routine transurethral catheterization is recommended for 1-3 days after colorectal
surgery
• Duration should be individualized
 Epidural analgesia
 Pelvic surgery
Prevention of Postoperative Ileus
• Limit opioid administration through use of multimodal anesthesia and analgesia
techniques
• Use minimally invasive surgical techniques when feasible
• Eliminate routine placement of NGT
• Use goal directed fluid therapy
Postoperative Glycemic Control
• Hallmark of physiological response to surgical trauma is insulin resistance
• Stress-reducing elements of ERAS
 Oral preoperative carbohydrate treatment
 Laparoscopic surgery
 Thoracic epidural analgesia

• Insulin treatment may be given especially for severe hyperglycemia

Postoperative Nutritional Care
• Any delay in resumption of normal oral diet after surgery is associated with increased
rates of infectious complications and delayed recovery
• Early oral diet has been found to be safe as early as 4 hours after surgery in patients
with new non-diverted colorectal anastomosis
• Low residue diet has been associated with less nausea, faster return of bowel function,
and shorter hospital stay
Postoperative Nutritional Care
• Surgical stress can cause acute depletion of arginine  impairment of T cell function
and wound healing
• Peri or postoperative immunonutrition (arginine, omega 3 fatty acids, ribonucleotides)
should be given to malnourished patients
 Reduction in infectious complications
Early Mobilization
• Important component of enhanced recovery after surgery programs
• Prolonged immobilization is associated with a verity of adverse effects
 Pulmonary complications
 Decreased muscle strength
 Thromboembolic complications
 Insulin resistance