Enhanced Recovery for Colorectal Patients

Caroline Jenkins and Inge Bateman

Department of Anaesthesia, Worthing Hospital

Western Sussex Hospitals NHS Trust

Aims of the Session

Inform you of how we manage analgesia for ER patients at Worthing Hospital

Inform you of what they do elsewhere with reference to analgesia for ER patients

Forum for discussion of current practice

Definition

‘An evidence based approach involving a select number of interventions which, when implemented as a group, demonstrate a greater impact on outcomes than when implemented as individual interventions.’

Enhanced Recovery Partnership Programme March 2010

Do you do ER?

If so what approach do you use?

Enhanced Recovery

Henrik Kehlet Denmark 1990s

Delivered in UK since the early 2000s

http://www.scitopics.com/Enhanced_Recovery_after_Surgery.html

Kahokehr A, Sammour T, Zargar-Shoshtari K, Hill AG

Background of Enhanced Recovery at Worthing Hospital

2007 project team set up for ER, agreed no patient selection (i.e. all inclusive service)

2008 first patients on ER pathway PCA, Paracetamol & NSAID. Epidural on indication.

2009 ER Nurse Specialist appointedTAP blocks, Ketamine, Paracetamol & NSAID, PCA or Morphine oral solution regularly & PRN. Epidural on indication.

With review of patients’ requirements for regular Morphine oral solution we changed the regime to PRN only and PCA on indication.

Audit

Oral Nutrition

Catheters

Gut motility

PONV

Analgesics

Mobilisation

Temperature Incisions

Fluids

Anaesthetic

Opioidsparing

NG Tubes

Premedication

CHO loadPre-op fasting

NoBowel Prep

Pre-admissionCounselling

Enhanced Recoveryafter Surgery

Adapted from Fearon et al 2005

Different Approaches to ER

Epidural

Spinal

PCA

Oral analgesia

TAP blocks

Local infiltration

Ketamine

Benefits of Epidurals

Thoracic is the classic approach

Reduction in pituitary, adrenocortical & sympathetic response

Opioid sparing

Does not modify immunological or inflammatory response

Problems Associated with Epidurals

Hypotension

Fluid ‘overload’

Slower to mobilise and eat

Longer length of stay

Failure

Benefits of Spinals

Improved mobilisation

Reduced opioid requirement

Fewer complications than epidurals

Problems Associated with Spinals

Risk of exaggerated cardiovascular changes

Risk of high block

What we do in Worthing

Pathway of a typical ER patient

The Enhanced Recovery Patient Pathway

Mr. C.R. 65 years old.

70Kg with a BMI of 24.

Surgical procedure: High Anterior Resection

PMH: Fit & No medications

Non-Smoker

Pre-op Assessment

Standard including bloods/ECG

ERP Nurse facilitator present

ERP explained => clear expectations

Ileostomy information offered

Discharge planning commenced

Admission Night Before

Bowel preparation

Carbohydrate drink 800mL midnight

Access to water until 6.00am

Surgery day

CHO drink 200mL 2 hours pre-op

Theatre 8.00

Standard Anaesthetic

Dexamethasone 8mg IV

Ketamine 40mg IV

Paracetamol 1g IV

Diclofenac 75mg IV

Oesophageal Doppler Cardiac monitor

Benefits of Ketamine

Opioid sparing

Reduces PONV

Zakine et al Anaesthesia and Analgesia Vol 106 (6) June 2008 1856-1860

Problems Associated with Ketamine

Optimal regime not established IV preparation unpleasant taste

Zakine et al Anaesthesia and Analgesia Vol 106 (6) June 2008 1856-1860

Operation

Laparoscopic sigmoid colectomy

Small incision to remove specimen

Duration – 150minutes

TAP block at the end of surgical procedure

Transversus Abdominis Plane Block

Ultrasound guided or blind technique

Easy to learn

Opioid sparing effect for open & lap surgery

McDonnell JG et al. Anesth Analg 2007;104:193-197

El-Dawlatly AA et al. BJA 2009;102:763-7

Transversus Abdominis Plane Block

Sensory supply from anterior rami of lower 6 thoracic nerves

Fascial plane between internal oblique & transversus abdominis

TAP Block Using Ultra Sound

Sterile Procedure

Sterile field

U/S probe protected

Patient position

Needle selection: regional block or Tuohy needles

Bilateral blocks 2 x 20mL 0.25%-0.5% chirocaine

Performing a TAP Block Using Ultra Sound

Identify landmarks

Advancement perpendicular to skin via Petit’s triangle with classical 2 pops

Oblique approach posterior to mid axillary line with real-time ultrasound guidance

Tissue compression aids clarity of image

Needle tip placement observed

Small volume injections assist confirmation of needle position

TAP Block Using Ultra Sound

http://www.medclip.com/scr/bd/8c/b5/bd8cb579349ec4f_2.jpg

TAP Block Using Ultra Sound

http://www.usra.ca/files/images/tap7.jpg

Performing a TAP Block (blind)

2 pops & a squirt

1. External oblique fascia

2. Internal oblique fascia transversus abdominis plane

Post-op Analgesia

Paracetamol 1g QDS PO

Ibuprofen 400mg QDS PO

Ketamine 20mg 4 hourly S/L (for 48 hours)

Morphine oral solution PRN (no post-op morphine used at all)

Morphine IV rescue analgesia for Recovery – not used

Post-op Day of Surgery

No nasogastric tube, No drain

Return to ward 14.30

Free Fluids – resource drinks

Out of bed 2 hours

Day 1 Post-op

Drip down, catheter out

Out of bed 08.00

3 x 60m walks, Self washing etc.

4 resource drinks

Breakfast, lunch, dinner and snacks

WR Note – Home later today or tomorrow

Acute Pain Ward Round – pain well controlled on mobilisation, deep breathing and coughing

Day 2 Post-op

Ward Round -

Doing well

Eating and drinking

Passing flatus

Home

Follow up by phone calls by ER nurse specialist

Recap of Analgesia used for ER Patients

at Worthing

Per-op Analgesia

Epidural on indication

Fentanyl

Paracetamol IV

Ketamine 0.5mg/kg

between induction & incision

Morphine

NSAID IV

TAP block

end of surgical procedure

Post-op Analgesia

Regular Paracetamol 1g QDS PO

Regular NSAID PO

Ketamine 15-20mg 4 hourly S/L (for 48 hours)

Morphine oral solution PRN

Occasionally PCA

Epidural on indication

Programme Figures in Relation to LOS

2002 2008 2009 2010(so far)

Mean 11.5 10 6.5 6.1

Median 12 8 5 5

Readmission Rates

2008 2009 2010(so far)

13% 11% 4.8%

CHKS Data

F.31 Complex large intestine

F.32 Very Complex large intestine

2009 Worthing lower lengths of stay than our peer hospitals.

Department of Health HES Data for elective

colorectal resection in England 2009

Length of stay by volume of cases, provider 2008-09 prov. to Dec:

Colorectal resection

0

20

40

60

80

100

120

140

160

180

200

- 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0

Mean length of stay (days)

No

. co

mp

lete

d e

lecti

ve c

ases Current Worthing ER

Length of stay

Summary

Worthing hospital currently use an effective ER regime without use of Epidural, Spinals or PCA that shows reduction in L.O.S and readmissions rates.

The research will be started shortly to add evidence to the clinical findings.

Any Questions

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