enhanced recovery after surgery (eras): immediate ......11/8/2019 5 chi creighton university medical...

11/8/2019

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Enhanced Recovery After Surgery (ERAS): Immediate & Potential Long Term Benefits

Mark D. Reisbig, M.D., Ph.D., FASA

Associate Professor & Associate Chair

Department of Anesthesiology & Perioperative Medicine

CHI Creighton University Medical Center Bergan Mercy

M.D., Ph.D. Program Director

Creighton University School of Medicine

CHI CREIGHTON UNIVERSITY MEDICAL CENTER BERGAN MERCY DEPARTMENT OF ANESTHESIOLOGY & PERIOPERATIVE MEDICINE


Disclosures

• None

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Overview

• ERAS Overview

• Surgical Stress Response & Cancer Patients

• Attenuation of Surgical Stress Response – ERAS Concepts

• ERAS Elements – Optimization, Multimodal Analgesia & Goal Directed Fluid Therapy

• Results from ERAS Work @ CUMC Bergan Mercy

ERASPRE‐ADMISSION OPTIMIZATION• Education & Counseling• Fitness & Prehabilitation• Nutrition & Immunonutrition• Glucose Control• OSA Screening Optimization• Smoking Cessation• Opioid Weaning• Anemia Optimization

PREOP ‐ DAY OF SURGERY• Limit NPO: CHO Loading• Normothermia• Multimodal Analgesia &

Regional/Neuraxial Analgesia• VTE Prophylaxis Begins• Antimicrobial Prophylaxis• Glucose Control

INTRAOP • Standardized Anesthetic Protocol• Normothermia• Glucose Control • Non‐Opioid Multimodal Analgesia• Antimicrobial Prophylaxis Continues• PONV Prophylaxis• Goal Directed Fluid Therapy

POSTOP • Standardized Care Protocol• Normothermia• Glucose Control • Non‐Opioid Multimodal Analgesia• Goal Directed Fluid Therapy• Early Resumption of Oral Intake• Early Mobilization• Early removal of catheters / tubes


ENHANCED RECOVERY GOALS IMPROVE PATIENT OUTCOMES

↓ LOS↓ SSI

↓ Complica ons

IMPROVED ANALGESIA ↓ or Eliminate Opioids

EARLY RESTORATION OF FUNCTIONAL STATUS

↓ SURGICAL STRESS RESPONSE

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Surgical Oncology: More than Immediate Outcomes

• “Surgical trauma results in systemic alterations that accelerate tumor development”

• Emerging data on short‐term & long‐term impacts of analgesia & anesthetic choices

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Perioperative Period Influence on Cancer Outcomes



Surgical Stress Response

Surgical & Anesthetic Plan, Analgesic Strategy, Overall Health of Patient

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• High adherence to ERAS protocol may be associated with improved 5‐yr cancer specific survival after colorectal cancer surgery

ERAS Related Attenuation of Stress Response & Cancer Survival ?

Surgical Optimization


savings from preve

VS

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OPTIMIZATIONObjective: Get Patients in Best Possible Condition for Surgery


• Standardized clinical assessment & management plans to optimize patients

• Time Sensitive = short window to achieve these goals in patients with cancer

PRE‐ADMISSION OPTIMIZATION• Education & Counseling• Fitness & Prehabilitation• Nutrition & Immunonutrition• Glucose Control• OSA Screening Optimization• Smoking Cessation• Opioid Weaning• Anemia Optimization

Analgesia


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Adverse Effects of Opioids



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Opioid Induced Hyperalgesia


High dose intraoperative opioid administration leads to increased postoperative opioid requirements

Preoperative Opioid Use & Immediate Outcomes

•Preoperative opioid use results in:•↑ LOS •↑ Readmissions•↑ Discharge to Skilled Nursing Facili es•↑ 90 day complica on rate•WEAN OFF 4‐6 weeks prior to surgery

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Adverse Effects of Opioids: Long‐Term Outcomes


Adverse Effects of Opioids: Long‐Term Outcomes


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Opioid Immunosuppression

OPIOIDS

Multimodal Analgesia: Opioid Avoidance

AcetaminophenNSAIDsKetamine gttDexamethasoneDextromethorphanGabapentinMagnesium gttIV Lidocaine gttDexmedetomidine gttU/S Guided Peripheral Nerve Blocks


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Fluid Therapy


Fluid Therapy

“Errors in fluid management (usually fluid excess) were the most common cause of perioperative morbidity and mortality.”

‐ Callum et al. 1999

**Callum KG, Gray AJG, Hoile RW et al. Extremes of Age: The 1999 Report of the National Confidential Enquiryinto Perioperative Deaths. London: National Confidential Enquiry into Perioperative Deaths; 1999.


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Curve A represents the hypothesized line of risk.

M. C. Bellamy Br. J. Anaesth. 2006;97:755-757

© The Board of Management and Trustees of the British Journal of Anaesthesia 2006. All rights reserved. For Permissions, please e-mail: [email protected]

HypovolemiaOrgan HypoperfusionSIRSSepsisMulti Organ Failure

HypervolemiaEdemaIleusPONVPulmonary ComplicationsCardiac Demands IncreaseWound Dehiscence

Bowel Ischemia

Bowel Edema


• HO’s responsible for 89% of fluid orders• <50% Aware of Na content in 0.9% Saline or daily Na Requirements • 25% prescribed 2 + liters of NS per day


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Salt

• What is the AHA daily recommended intake of sodium for a healthy person?

AHA Recommends 2300 mg/day


Drowning Patients in the Brine?

• How much sodium in units of sodium per bag of Lays Big Grab Potato Chips (2.5oz) is in a single 1 liter bag of Normal Saline?


• 170 mg Na per 1 oz serving• 425 mg Na per Big Grab Bag

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1 Liter Normal Saline = 9000mg NaCl = Na Content of 21 Bags of ChipsCHI CREIGHTON UNIVERSITY MEDICAL CENTER BERGAN MERCY DEPARTMENT OF ANESTHESIOLOGY & PERIOPERATIVE MEDICINE

Classic Approach ‐ 4:2:1 (Holliday & Segar 1957)


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Classic Fluid Guidance (OLD WAY)

• Traditional fluid management maintenance = 4:2:1 rule• Fluid deficit = maintenance x NPO duration

• Blood replacement 3:1 crystalloid

• “3rd space losses” 12‐18 ml/kg/hr

• 120 kg male for 4 hour open colectomy fasting for 12 hours with 500 ml blood loss

• Maintenance fluid/hour = 160 ml/hr x 12 hours for NPO deficit = 1,920 ml

• 15 ml/kg/hr for large open abdominal case = 120 kg x 15 ml/kg x 4hr = 7,200 ml

• Replace blood loss at 3:1 = 1500 ml

• TOTAL FLUID ADMINISTRATION = 10,600 ml

• 10.6 Kg weight gain

• Na load (NS) 41.5x daily recommended intake


Patient from Previous Slide10.6 L NS = 95,400mg NA = 224.4 Bags Lays Big GrabOver 41.5 x AHA Daily Allowance Sodium Intake


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Goal Directed Fluid Therapy

• SVV, PPV, PVI allow for more accurate volume resuscitation w/ improved markers of perfusion such as lower base deficit & lactate


Intraoperative Fluid Management

• Paradigm shift• Will intravenous fluid improve cardiac output?• How do we know this?

• 1) Measure “fluid responsiveness”

• 2) Measure cardiac output continuously

Thiele RH et al. Canadian Journal of Anesthesia 62: 169, 2015

ERAS Fluid Administration ‐ Colorectal Study


The impact of perioperative fluid therapy on short-termoutcomes and 5-year survival among patients undergoingcolorectal cancer surgery e A prospective cohort study

within an ERAS protocol

D. Asklid a,b, J. Segelman c,d, C. Gedda b,e, F. Hjern a,b,K. Pekkari a,b, U.O. Gustafsson a,b,*

Available online at www.sciencedirect.com

ScienceDirect

EJSO 43 (2017) 1433e 1439 www.ejso.com

Improved 5‐year survival rates in colorectal cancer patients w/ < 3L IV fluid administered on day of surgery

Improved short term outcomes w/ < 3L IV fluid administered on day of surgery

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RESULTS


CUMC Cytoreductive Surgery + HIPEC


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CUMC Bergan Cytoreductive Surgery + HIPEC Results

Erika Samlowski MD, et al. Society for Thermal Medicine Annual Meeting, St. Pete’s Beach, FL May 2019

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Pre‐ERAS ERAS

% Requiring Opioid PCA

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Pre‐ERAS ERAS

% Requiring Any Postoperative Opioid


Cytoreductive Surgery + HIPEC Results

Erika Samlowski MD, et al. Society for Thermal Medicine Annual Meeting, St. Pete’s Beach, FL May 2019

Time to Return of Bowel Function

0

1

2

3

4

5

6

Pre‐ERAS ERAS

Time to Resumption of General Diet


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0

1

2

3

4

5

6

7

8

9

10

Pre‐ERAS ERAS

Length of Stay

Cytoreductive Surgery + HIPECErika Samlowski MD, et al. Society for Thermal Medicine Annual Meeting, St. Pete’s Beach, FL May 2019


***

*** Lowest LOS for this Procedure in the World

Decrease SSIDecrease LOS

Decrease ReadmissionsDecrease/Eliminate Opioids

Decrease Pain/Improve ComfortImprove Outcomes

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CUMC Bergan Colorectal Surgery Preliminary Data

• Entereg (alvimopam): Peripheral Opioid Antagonist = $1250/course

• Need for opioid antagonist eliminated not giving systemic opioids

• ~280 colorectal cases / year = Cost savings ~ $350,000 per year


CHI Colorectal: ERAS Protocol

Colorectal: Non ERAS Protocol

None

HydromorphoneIV 0.5 mg Q 1 hr

CUMC Bergan Colorectal Surgery: Improved Pain Scores

Postop Opioid Administration


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Obstetrics & GynecologyERAS Live in Omaha Metro Hospitals 3/14/19


CHI Urology/Gyn ‐ ERAS Protocol

CHI Gynecology ‐ ERAS Protocol

None

None

Postop Opioid Administration

CHI ANESTHESIOLOGY AT CUMC‐BERGAN MERCY & MIDLANDS DEPARTMENT OF ANESTHESIOLOGY & PERIOPERATIVE MEDICINE DEPARTMENT OF OBSTETRICS & GYNECOLOGY CREIGHTON UNIVERITY SCHOOL OF MEDICINE INTEGRATED CARE PATHWAY FOR ENHANCED RECOVERY

MAJOR GYN / HYSTERECTOMY PROTOCOL


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ERASPRE‐ADMISSION OPTIMIZATION• Education & Counseling• Fitness & Prehabilitation• Nutrition & Immunonutrition• Glucose Control• OSA Screening Optimization• Smoking Cessation• Opioid Weaning• Anemia Optimization

PREOP ‐ DAY OF SURGERY• Limit NPO: CHO Loading• Normothermia• Multimodal Analgesia &

Regional/Neuraxial Analgesia• VTE Prophylaxis Begins• Antimicrobial Prophylaxis• Glucose Control

INTRAOP • Standardized Anesthetic Protocol• Normothermia• Glucose Control • Non‐Opioid Multimodal Analgesia• Antimicrobial Prophylaxis Continues• PONV Prophylaxis• Goal Directed Fluid Therapy

POSTOP • Standardized Care Protocol• Normothermia• Glucose Control • Non‐Opioid Multimodal Analgesia• Goal Directed Fluid Therapy• Early Resumption of Oral Intake• Early Mobilization• Early removal of catheters / tubes


ENHANCED RECOVERY GOALS IMPROVE PATIENT OUTCOMES

↓ LOS↓ SSI

↓ Complica ons

IMPROVED ANALGESIA ↓ or Eliminate Opioids

EARLY RESTORATION OF FUNCTIONAL STATUS

↓ SURGICAL STRESS RESPONSE

SURGICAL ONCOLOGY↓ IMMUNOSUPRESSION

↓ METASTASIS ↑ SURVIVAL

Questions & Discussion


enhanced recovery after surgery (eras): immediate ......11/8/2019 5 chi creighton university medical...

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