Implementing an enhanced recovery pathway in your surgical practice

June 13, 2019

Bruce S. Kahn, MD, FACOG

Dr Kahn is Director, Scripps Fellowship in Minimally Invasive Gynecologic Surgery, and practices Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Scripps Clinic Medical Group, San Diego, California.

Tips to provide better care for patients and improve the value of the healthcare dollar.

References:

1. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg. 2014 Jun;38(6):1531-41.2. Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AF. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg. 2014 Feb;101(3):172-88.3. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: a review. JAMA Surg. 2017 Mar 1;152(3):292-298.4. Lawrence D. Egbert, M.D., George E. Battit, M.D., Claude E. Welch, M.D., and Marshall K. Bartlett, M.D. Reduction of postoperative pain by encouragement and instruction of patients - a study of doctor-patient rapport. N Engl J Med. 1964; 270:825-8275. L.T. Sorenson. Wound healing and infection in surgery: the pathophysiologic impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann. Surg. 2012;266(6): 1069 â 1079.6. Wong J, Lam DP, Abrishami A, Chan MT, Chung F. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth. 2012 Mar;59(3):268-79.7. Oppedal K, MÃ¸ller AM, Pedersen B, TÃ¸nnesen H. Preoperative alcohol cessation prior to elective surgery. Cochrane Database Syst Rev. 2012 Jul 11;(7):CD008343.8. Tonnesen H, Kehlet H. Preoperative alcoholism and postoperative morbidity. Br J Surg. 1999;86:869â874.9. Tonnesen H, Rosenberg J, Nielsen HJ, et al. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. BMJ. 1999;318:1311â131610. Arnold A, Aitchison LP, Abbott J. Preoperative mechanical bowel preparation for abdominal, laparoscopic, and vaginal Surgery: a systematic review. J Minim Invasive Gynecol. 2015 Jul-Aug;22(5):737-52.11. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003;(4):CD004423.12. Smith MD1, McCall J, Plank L, Herbison GP, Soop M, Nygren J. Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev. 2014 Aug 14;(8):CD009161.13. Walker KJ, Smith AF. Premedication for anxiety in adult day surgery. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD002192.14. Moiniche S, Henrik K, Dahl J. A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief: The role of timing of analgesia. Anesthesiology. 2002:96:725-41.15. Choosing Route of Hysterectomy for Benign Disease. Committee Opinion No. 701. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2017:129:e155â9.16. Ohtani H, Tamamori Y, Arimoto Y, Nishiguchi Y, Maeda K, Hirakawa K. A meta-analysis of the short- and long-term results of randomized controlled trials that compared laparoscopy-assisted and conventional open surgery for colorectal cancer. J Cancer. 2011;2:425-34.17. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004929.18. Hart S, Bordes B, Hart J, Corsino D, Harmon D. Unintended perioperative hypothermia. Ochsner J. 2011 Fall;11(3): 259â270.19. Schol PB, Terink IM, LancÃ© MD, Scheepers HC Liberal or restrictive fluid management during elective surgery: a systematic review and meta-analysis. J Clin Anesth. 2016 Dec;35:26-39.20. Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg. 2012 Mar;114(3):640-51.21. Miller TE, Raghunathan K, Gan TJ. State-of-the-art fluid management in the operating room. Best Pract Res Clin Anaesthesiol. 2014 Sep;28(3):261-73.22. Charoenkwan K, Matovinovic E. Early versus delayed oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev. 2014 Dec 12;(12):CD004508.23. Wong M, Morris S, Wang K, Simpson K. Managing Postoperative pain after minimally invasive gynecologic surgery in the era of the opioid epidemic. JMIG. 2017 Sept24. Nelson G, Altman A, Meyer LA, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations â Part II. Gynecologic Oncol. 140. 2016 323-332.

Implementing an enhanced recovery pathway in your surgical practice

Studies have shown that patients on enhanced recovery pathways (ERP) have fewer complications, a shorter length of hospital stay and attain a higher level of satisfaction with their surgical experience.^1-2

The essentials of ERPs include

Reducing surgical stress

Maintaining normal physiological function perioperatively

Expediting postoperative recovery.¹

In 2016 the ERAS^RSociety published guidelines for gynecologic/oncology surgery.

Preoperative education and counseling

Encouraging patients to actively participate in their recovery facilitates improved compliance and outcomes.

Counseling should emphasize day-to-day goals and expectations during the entire perioperative period.

Patients should receive counseling on pain management strategies and education on opioid risks and ways to minimize opioid use after surgery

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Preoperative optimization

Optimization allows the body to prepare for the stress of surgery and reduces surgical morbidity.¹

Emphasis should be placed on cessation of tobacco and excessive alcohol use for at least 4 weeks prior to surgery to promote would healing and reduce post-operative complications.^5-9

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Hormone replacement therapy and oral contraceptives

Consideration should be given to discontinuation of these therapies prior to surgery due to the risk of postoperative thromboembolism.

Thromboprophylaxis should be utilized for patients utilizing these therapies at the time of surgery.

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Preoperative bowel preparation

Avoid routine use of mechanical bowel preparation for patients undergoing benign gynecologic procedures.

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Preoperative fasting and carbohydrate loading

Carbohydrate loading with a clear fluid containing complex carbohydrates is known to attenuate insulin resistance, minimize protein and muscle loss, and improve patient comfort.¹²

Patients are instructed to drink 3 12-oz bottles of Clearfast or Gatorade before their scheduled surgical time, with the last bottle to be consumed 2 hours before anesthesia.

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Preanesthetic medications/nausea prophylaxis

Avoid use of long-acting anxiolytics prior to surgery with administration of short-acting agents only as necessary.

Consider other strategies to reduce anxiety, including an emphasis on preoperative counseling and education.

Consider beginning multimodal non-opioid analgesics preoperatively including a long-acting oral nonsteroidal anti-inflammatory drug (NSAID), acetaminophen, and possibly gabapentin. Continue the use of multimodal non-opioid analgesics as a mainstay of postoperative pain control.

A focus on multimodal postoperative nausea and vomiting prophylaxis and prevention throughout the perioperative period should be utilized.

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Minimally invasive surgery

Minimally invasive approaches to gynecologic surgery, by way of vaginal, traditional laparoscopic or robotic-assisted approaches, are strongly recommended.^{15, 16}

Standard anesthetic protocol

Anesthetic protocols that allow for rapid recovery, including use of short-acting agents, are strongly encouraged.

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Nasogastric intubation

Nasogastric (NG) and orogastric tubes should be removed prior to patient awakening.

Routine placement of NG tubes until return of bowel function is no longer recommended.¹⁷

Preventing interoperative hypothermia

Modalities to prevent intraoperative hypothermia include temperature monitoring, active surface body warming systems, and pre-warmed IV fluids.

Perioperative fluid management

ERPs emphasize the concept of euvolemia, or a zero-fluid balance.

Carbohydrate loading and hydration allows maintenance of a euvolemic state and mitigates the need for excessive fluid resuscitation intraoperatively.

Postoperative fluid therapy/nutrition

IV hydration can be discontinued once patients are tolerating clear liquids, which in most cases can be safely resumed immediately after surgery.²²

For patients not discharged same-day, advancement to regular diet can be instituted upon arrival to floor.

Postoperative analgesia

Acetaminophen and NSAIDs are the cornerstone of postoperative pain management and can effectively reduce opioid consumption without compromising pain control or recovery.²³

When used, oral opioid administration is preferred.

Peritoneal/urinary drains

It is recommended that routine peritoneal drainage be avoided in gynecologic/oncologic surgery.

Urinary catheters should be utilized for a short duration, ideally less than 24 hour after surgery.

Early mobilization

Encouraging patients to mobilize within 24 hours after surgery is strongly recommended.