Starved and Drowned

Ken Fearon

Powerpoint File

Philosophy of ERAS

Traditional perioperative care has tended to expose the patient to unnecessary fasting, excess intravenous fluids and an uncontrolled stress response1. Enhanced recovery is based on a holistic approach, applied throughout the surgical patient’s journey. The principle behind enhanced recovery is simply to minimise the magnitude and number of insults sustained by a patient undergoing elective surgery – if you don’t drive the patient down, they won’t need to come back up!

Key targets

The key elements of enhanced recovery focus on what might inhibit a patient returning home after major abdominal surgery? The areas of concern include pain requiring parenteral analgesia, the need for intravenous fluids combined with absent oral food and fluid intake, and finally, the inability to mobilise to allow activities of daily life. Enhanced recovery attempts to optimise organ function in the post-operative period such that as soon as possible the patient only requires oral analgesia, is eating and drinking normally and has been fully mobilised. When these goals have been reached, the patient is functionally recovered and can be discharged home.

Evidence-based Practice

The aims of an ERAS programme are achieved by an integrated, multidisciplinary care pathway built on evidence-based practice and applied throughout the patient’s surgical journey. Elements include avoiding the use of bowel prep, giving patients fluid and carbohydrate loading pre-op, using epidural anaesthesia and analgesia, using minimally invasive surgical techniques, avoiding intravenous fluid and sodium overload, early commencement of oral fluids and diet and a defined programme for mobilisation out of bed. These issues have been described in detail in recent publications2. What remains to be established is how best to implement enhanced recovery programmes into all aspects of surgical, anaesthetic and nursing practice and into different health-care systems.

Improvements in Outcomes

At present it is evident that substantial improvements in patient outcomes can be achieved by implementation of enhanced recovery programmes both in terms of functional recovery and length of hospital stay. For example, in colorectal surgery length of stay can be reduced from 7-9 days to 2-5 days 3, 4. This presentation will focus on the contribution to recovery from optimal nutritional care/fluid balance.

References

1. Lassen K, Hannemann P, Ljungqvist O, Fearon K, Dejong CH, von Meyenfeldt MF et al. Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 2005;330:1420-1.

2. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005;24:466-77.

3. Nygren J, Hausel J, Kehlet H, Revhaug A, Lassen K, Dejong C et al. A comparison in five European Centres of case mix, clinical management and outcomes following either conventional or fast-track perioperative care in colorectal surgery. Clin Nutr 2005;24:455-61.

4. Basse L, Hjort Jakobsen D, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000;232:51-7.