DEBATE?DEBATE?

THERE IS NO THERE IS NO DEBATEDEBATE

Traditional Perioperative CareTraditional Perioperative Care

•StarveStarve

•StressStress

•DrownDrown

Enhanced recovery after surgeryEnhanced recovery after surgery

Fu

nct

ion

al c

apac

ity

Fu

nct

ion

al c

apac

ity

SurgerySurgery Multi-modal interventionMulti-modal intervention

Traditional careTraditional care

DaysDays WeeksWeeks

Preop

Audit of compliance & outcomes

HomeSurgery

↨Anesthesia

WardHDU

CLINIC

PATIENT’S JOURNEY

KCH Fearon 2004

Preadmissioncounselling

Selective bowel-prep

CHO- loading/no fasting

No - premed

No NG tubes

Thoracic epidural Anaesthesia

Short-acting Anaesthetic agent

Avoidance ofSodium/fluid overload

Short incisionsWarm air bodyheating in theatre

Standard mobilisation

Non-opial oralAnalgetics/NSA ID`s

Prevention of nausea and vomiting

Stimulation of gut mobility

Early removal ofcatheters/drains

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Core Protocol

FLUIDSFLUIDSFOODFOOD

BALANCED IS BALANCED IS BETTERBETTER

ELECTIVE SURGERYELECTIVE SURGERYRESUSCITATIONRESUSCITATION

WET IS BESTWET IS BEST

Post-op Weight GainPost-op Weight GainFollowing Colorectal ResectionFollowing Colorectal Resection

Lobo et al, Lancet Lobo et al, Lancet Brandstrup et al, 2002; Brandstrup et al, 2002; 359359: 1812-18 : 1812-18 Annals Surg 2003; Annals Surg 2003; 238238: 641-8: 641-8

3-6kg

KCH Fearon 2004

HypothesisHypothesis

Fluid/SalineFluid/Saline

OverloadOverload

Hypoalbuminaemia/Acidosis/HyperchloraemiaHypoalbuminaemia/Acidosis/Hyperchloraemia

Gut oedema/MalfunctionGut oedema/Malfunction

Delayed recoveryDelayed recovery

Effect of salt and water balance in recovery of Effect of salt and water balance in recovery of gastrointestinal function after elective colonic gastrointestinal function after elective colonic

resectionresection

20 colonic resection20 colonic resection

patientspatients

1010 10 10

Standard IVStandard IV Restricted IV*Restricted IV*

fluidsfluids fluids fluids

(* 2l H(* 2l H220 and 77mmol NaCl)0 and 77mmol NaCl)

Lobo et al, 2002 Lobo et al, 2002 Lancet; 359: 1812-8Lancet; 359: 1812-8

Effect of fluid and salt restriction in post-Effect of fluid and salt restriction in post-op recoveryop recovery

-2-2

-1-1

00

11

22

33

44

55 Standard GroupStandard Group

Restricted GroupRestricted Group

p<0.0001p<0.0001

Ch

ange

in w

eigh

t (k

g)C

han

ge in

wei

ght

(kg)

0 1 2 3 4 50 1 2 3 4 5Postoperative daysPostoperative days

Standard GroupStandard GroupRestricted GroupRestricted Group

2525

3030

3535

4040

Ser

um

alb

um

in (

g/L

)S

eru

m a

lbu

min

(g/

L)

p=0.01p=0.01

PreopPreop

1 2 3 4 5 61 2 3 4 5 6

Postoperative daysPostoperative days

Effect of fluid and salt Effect of fluid and salt restriction in post-op recoveryrestriction in post-op recovery

Soli

d p

hase

gas

tric

em

ptyi

ng

Soli

d p

hase

gas

tric

em

ptyi

ng

tim

e T

tim

e T

5050 (

mm

) (

mm

)

250250

200200

150150

100100

5050

00

n=10n=10n=10n=10

p=0.028p=0.028

Standard Restricted Standard Restricted Group GroupGroup Group

Liq

uid

phas

e gs

ric

empt

yin

g L

iqui

d ph

ase

gsri

c em

ptyi

ng

tim

e T

tim

e T

5050 (

min

) (

min

)

200200

150150

100100

5050

00

n=10n=10n=10n=10

p=0.017p=0.017

Standard Restricted Standard Restricted Group GroupGroup Group

Post-op Fluid ManagementPost-op Fluid Management

TRADITIONALTRADITIONAL

BALANCEDBALANCED

4-6L4-6L

2-3L2-3L

2-3L2-3L1-2L1-2L

OPERATIONOPERATION POST-OPPOST-OP

2-4d2-4d

1-2d1-2d

What is the evidence base What is the evidence base to suggest that to suggest that

BALANCED fluid BALANCED fluid management can management can

improve outcomes?improve outcomes?

Effects of IV fluid restriction on Effects of IV fluid restriction on post-op complicationspost-op complications

172172Colorectal resectionColorectal resection

patientspatients

8686 8686 Standard IVStandard IV Restricted IV Restricted IV fluidsfluids fluids fluids

7272 69 69 competedcompeted completed completed

Brandstrup et al, Brandstrup et al, 2003; 2003; 238238: 641-8: 641-8

Number of Patients with Complications Number of Patients with Complications (Per-Protocol Analysis)(Per-Protocol Analysis)

Restricted Restricted GroupGroup

Standard Standard GroupGroup

p valuep value

Overall complicationsOverall complications 2121 4040 0.0030.003

Major complications Major complications †† 88 1818 0.0400.040

Minor complications Minor complications †† 1515 3636 0.0000.000

Tissue-healing complications Tissue-healing complications †† 1111 2222 0.0400.040

Cardiopulmonary complications Cardiopulmonary complications †† 55 1717 0.0070.007

Blinded AssessmentBlinded Assessment

Effect of Intra-operative Fluid Management Effect of Intra-operative Fluid Management on Outcome after Intra-abdominal Surgeryon Outcome after Intra-abdominal Surgery

Nisanerich et al 2005, Anaesthesiology; 103: 25-32Nisanerich et al 2005, Anaesthesiology; 103: 25-32

n=152n=152

n=75n=75 n=77n=77

RandomisedRandomised

Liberal regimenLiberal regimen(Bolus 10ml/kg followed(Bolus 10ml/kg followed

By 12ml/kg/hr)By 12ml/kg/hr)

Restricted regimenRestricted regimen(4ml/kg/hr)(4ml/kg/hr)

3.8 3.8 ± 1.2 L± 1.2 L

2.0 2.0 ± 0.5 L± 0.5 L

2.0 2.0 ± 0.5 L± 0.5 L

1.9 1.9 ± 0.5 L± 0.5 L

1.4 1.4 ± 1.0 L± 1.0 L

2.2 2.2 ± 0.5 L± 0.5 L

2.1 2.1 ± 0.5 L± 0.5 L

2.0 2.0 ± 0.5 L± 0.5 L

Intra-opIntra-op

Day 1Day 1

Day 2Day 2

Day 3Day 3

<0.001<0.001

N.S.N.S.

N.S.N.S.

N.S.N.S.

PP

Effect of Intra-operative Fluid Effect of Intra-operative Fluid Management on Outcome after Intra-Management on Outcome after Intra-

abdominal Surgeryabdominal Surgery

Nisanevich et al 2005, Anaesthesiology; 103: 25-32Nisanevich et al 2005, Anaesthesiology; 103: 25-32

OutcomeOutcome RestrictedRestricted LiberalLiberal PP

No. of pts with No. of pts with complicationscomplications

1313 2323 <0.05<0.05

Length of stay (d)Length of stay (d) 88 99 <0.01<0.01

Moved bowels (d)Moved bowels (d) 44 66 <0.001<0.001

If you Limit Intra-operative Fluids If you Limit Intra-operative Fluids (10ml/kg/hr), does Early Discontinuation of (10ml/kg/hr), does Early Discontinuation of

IV Fluids Influence Outcome?IV Fluids Influence Outcome?

Makay et al Makay et al (sumbitted)(sumbitted)

n=80n=80

ColorectalColorectal

n=41n=41 n=39n=39

STANDARDSTANDARD LIMITEDLIMITED3L H3L H220/d0/d

154mmol Na/d154mmol Na/d3d3d

2L H2L H220/d0/d

60mmol Na/d60mmol Na/d1d1d

Effect of Restricted Intra-op Effect of Restricted Intra-op Fluids Plus Discontinuation of IV Fluids Plus Discontinuation of IV

Fluids on Day 1Fluids on Day 1

Makay et al (submitted)Makay et al (submitted)

RestrictedRestricted ‘‘Liberal’Liberal’ PP

No of complicationsNo of complications 1414 1010 NSNS

Length of stay (day)Length of stay (day) 66 66 NSNS

Moved bowels (day)Moved bowels (day) 44 44 NSNS

BALANCEDBALANCEDISIS

BESTBEST

Postoperative early enteral Postoperative early enteral nutritionnutrition

Lewis BMJ 2001

Traditional Care Day1

ERAS Day1

Nygren Clin Nutr 2003

Food intake

0

400

800

1200

1600

1 2 3 4

Postop days

kcal

/ 24

h

Effect of ERAS on spontaneous Effect of ERAS on spontaneous oral diet oral diet

traditional care enhanced-recovery protocol

Complications, length of stay and readmissions Complications, length of stay and readmissions within 30 days of colorectal resectionwithin 30 days of colorectal resection

ERASERASn = 425n = 425

Traditional*Traditional*n = 451n = 451

PP

Anastomotic leak % Anastomotic leak % 4.24.2 3.93.9

Mortality %Mortality % 1.21.2 1.51.5

Actual length of stay (days) Actual length of stay (days) (median)(median) 55 88 <0.01<0.01

* Nygren et al Clin Nut 2005;24:455-461

ERAS GROUP

THE ENDTHE END