ENHANCED RECOVER AFTER SURGERY IMPROVED SAFETY

Transcription

1 ENHANCED RECOVER AFTER SURGERY IMPROVED SAFETY

2 TELEFLEX CONSULTANT AND ADVISORY BOARD DISCLOSURES B BRAUN CONSULTANT AND ADVISORY BOARD NO DIRECT CONFLICTS

3 10/13/2018 Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional 3

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5 START HAPPY HOUR specific procedure TEAM Design Protocols EDUCATE Redo Corner Slot Implement Start in your area Add more areas C-Sections FREE TURN Provide Updates

6 10/13/2018 Enhanced Recovery The concept of enhanced recovery started 1990s with FAST TRACKING. The ERAS Society in Europe was formed in The first international ERAS Society Congress was held in France in In the United States (US) interest in enhanced recovery has been growing since the late 2000s. The Duke University Medical Center Enhanced Recovery Program started in 2010 The first US Enhanced Recovery Congress organized by the Duke University Department of Anesthesiology and Surgery was held in Washington DC in The 2nd US Enhanced Recovery program was held in New Orleans in October 2014, and marked the official launch of the American Society of Enhanced Recovery (ASER). Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc Gustafsson U. O., Scott M. J., Schwenk, W., et. al. Guidelines for perioperative care in elective colonic Surgery: Enhanced Recovery After Surgery (ERAS ) Society Recommendations. 2013; 37 (2):

7 LET THE ERAS GAME BEGIN Caution Selecting Members Build a team!

8 Choose a Specific Case Colorectal TEAM Getting Started Protocols Educate Nursing staff Surgeons Anesthesia Journal Club

9 Negative People Treat with Evidence!!

10 10/13/2018 Enhanced recovery Reduce care time by more than 30% A recent study demonstrated that ERAS programs allow patients to recover much faster after their operation and this reduces the need for hospital stay by about 30% or more than 2 days after major abdominal surgery. Despite earlier discharge from the hospital, readmissions did not increase (Greco et al. World Journal of Surgery : ). Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc Gustafsson U. O., Scott M. J., Schwenk, W., et. al. Guidelines for perioperative care in elective colonic Surgery: Enhanced Recovery After Surgery (ERAS ) Society Recommendations. 2013; 37 (2):

11 Enhanced Recovery Reduce complications by up to 50% ERAS reduce major complications after abdominal surgery by as much as 40%. In particular non-cardiac complications, such as those from the lungs and cardiovascular systems are markedly reduced (Greco et al. World Journal of Surgery : )

12 Anesthesia Plan Preoperative Patent Education Preoperative- Preanesthesia clinic Bowel Prep Oral Carbohydrate Drink up to 2 hours before surgery Minimize Starvation Times Preoperative Assessment and Optimization

13 Decrea And Da Cancell Success in Clinic Negative SURGEON! AND ANESTHESIA PROVIDERS

14 Preoperative Patient Education Shame free educational Environment Allow for questions! Appropriate literacy level Check for Health Literacy Do they know their medications and what they do? Reliable electronic teaching and websites Integration of Meaningful images Set Goals and Expectations for Ambulation and Discharge Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc /13/

15 Preoperative Assessment and Optimization Medical Optimization Prior to Surgery Be Mindful of time constraints! Preoperative optimization and risk stratification May need to consult with Patients Primary Care or specialist if Clinical judgement of a improvable condition. ACC/AHA Risk Assessment >4 Mets Active CHF, Unstable Angina, Unstable Arrhythmia, Major Valve Lesion, Pulmonary HTN, and Cardiomyopathy Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc /13/

16 Preoperative Assessment and Optimization Preoperative Testing Lancet 2003 article by Garcia et al % preoperative testing was not necessary if a good preoperative assessment was completed. CBC and Chemistry indicated within 30 days ACC/AHA METS <4 plus 2 or more risk factors: CAD, CHF, Insulin DM > 20 years, CVA, Renal Insufficiency Feely et al recommend test due to medical necessity indicated test that will change management or better assess risk/anesthesia choice. Screening vs Surveillance or targeted indicated test due to status change

17 Preoperative Assessment and Optimization Pulmonary Risk and Optimization Smoking history and promotion of cessation Incentive Spirometry one week prior to surgery 10 times per hour while awake- Caution with COPD Patients!! Severe COPD ABG for CO2 Retention. 6 minute walk test Preanesthesia Clinic Upstairs and long hallway Obtain previous ABG s and Pulmonary Function Studies 10/13/2018 Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc

18 10/13/2018 Preoperative Assessment and Optimization Optimization in Hemoglobin, HTN, and DM Hemoglobin preferred Iron correction HTN <180 mmhg Systolic and < 110 mmhg Diastolic ACE inhibitors and Angiotension II Receptor antagonist higher risk for Hypotension hold am of surgery but resume postoperative if euvolemic and normal renal function Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc

19 Optimization in Hemoglobin, HTN, and DM Preoperative Assessment and Optimization DM A1c and glucose control and optimization preoperative to prevent surgical infections! Most common complications Hold oral hypoglycemic agents consult with primary care or endocrinologist for insulin recommendations. Usually ½ lacking insulin the night before and Short acting sliding scale.. Improved cardiopulmonary Fitness Recovery for Chemotherapy Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc /13/

20 Minimize Starvation times Clear Fluids up to 2 hours before Anesthesia Induction Clinical Judgement Elevated A1c Significant GERD BMI > 40 Gastroparesis/Peripheral Neuropathy 10/13/2018 Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc

21 Preoperative carbohydrate drink mimics breakfast and promotes insulin release. This will help decrease the peripheral insulin resistance secondary to surgical stress. Oral Carbohydrate Drink up to 2 hours before surgery More stable Glycemic control perioperative Clearfast ( 21g monosaccharides, 38g polysaccharides, 230 calories per 12 oz)

22 Bowel Prep- To Prep or Not? Current Evidence supports Mechanical Bowel Prep with Oral Antibiotics! Types of Mechanical Isosmotic Balanced Electrolyte Solutions-PEG(polyethylene glycol) 4 liters Due to HIGH molecular weight nonabsorbable passes through GI tract without net absorption or secretion Avoids Electrolyte and fluid shifts Most common Side Effect? Nausea Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc /13/

23 Bowel Prep- To Prep or Not? Current Evidence supports Mechanical Bowel Prep with Oral Antibiotics! Types of Mechanical Hyperosmotic( Magnesium Citrate & Sodium Phosphate) They draw water into intestines and cause fluid and electrolyte shifts. Could result in Renal Issues Not Recommended by Enhanced Recovery Protocols Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc /13/

24 Anesthesia Plan Preoperative Antiemetic Risk Assessment and Utilization of Two Agents Hemodynamic Monitoring for Either Fluid Restrictive or Volume and Cardiac Optimization Techniques- Goal Directed Therapy Female, Hx PONV or Motionsickness, Nonsmoker, younger age, use of inhaled anesthetics, opioids, duration of anesthesia and type of surgery (abdominal/laparoscopic surgery) ASA 1&2 Fluid Restrictive Technique Any system least invasive Cheetah, Esophageal Doppler, pleth variability, etc. ASA 3 Volume Cardiac Optimization- SV analysis Esophageal Doppler or FloTrac ASA 4 Volume Cardiac Optimization not on Enhanced Recovery Protocol Sv Analysis Esophageal Doppler, TEE, and/or FloTrac- consider ScVo2. 10/13/2018 Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc

25 Anesthesia Plan Analgesic Management Intrathecal Morphine plus Single or Continuous TAP Blocks Epidural low thoracic Multimodal Opioid Reduction Techniques

26 Anesthesia Plan- PONV Drugs Dosage Timing Dexamethasone 4-8mg IV At induction Ondansetron 4mg IV End of Case Scopolamine Transdermal Patch Prior Night or 2 hour Prior to surgery Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major 10/13/2018 abdominal surgery. West Islip, NY Professional Communication Inc

27 PONV Rescue Drugs Dosage Instructions Promethazine 2.5mg IV Dilute 25mg to 2.5/ml Droperidol mg IV Haloperidol 0.5mg-<2mg Dilute 1mg/ml caution not IM only Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major 10/13/2018 abdominal surgery. West Islip, NY Professional Communication Inc

28 Preoperative Pain Management Multimodal Drug Dosage Timing Acetaminophen 1000mg IV Induction Gabapentin 600mg PO 2 Hours Prior to Surgery Celecoxib 400mg PO 2 hrs prior to surgery Caution with Elderly and Renal Intrathecal Morphine or Low Thoracic Epidural 200mcg Immediately Preop Alvimopan Entereg 12mg PO 2 hours prior to surgery if not on Opioids for 2 weeks Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal 10/13/2018 surgery. West Islip, NY Professional Communication Inc

29 Antibiotic Prophylaxis More aggressive dosages and more frequent Re-dosing to improve plasma level at closure. Surgical Infection the most common complication Cefazolin 1g <80kg, 2g>80kg, 3g >120kg. Redose in 3-4 hours to avoid nadir during closure. Clindamycin 600mg, 900mg, and 1200mg Closure is cleaner with hand assisted barriers used.

30 Maintain: Warming blankets in the preoperative setting. Do not make them sweat! Monitor: Temperature should be monitored during the perioperative period Normothermia Prevent: Increasing Room Temperature Increasing Surgical Team awareness Treatment: Forced air warmers and fluid warmers for ALL Enhanced Recovery Cases 10/13/2018 Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc

31 Intraoperative Period SCD s Administer Antibiotics- Not 5 seconds or 59 minutes prior to incision Administer Multimodal Analgesia Protocol AVOID OPIOIDS!!!!! Goal Directed Fluid Therapy Maintain Normothermia Minimize Tubes Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc /13/

32 Intraoperative Period Multimodal Utilizing Non-Opioid Techniques Primary Goal AVOID OPIOIDS TIVA with Propofol or as adjunct to Inhaled Anesthetics 15 mg ketorolac IV at the end of case if ok with surgeon and not contraindicated IV 1000mg Acetaminophen with induction

33 Intraoperative Period Magnesium 30-50mg/kg bolus over 30minutes then 20mg/kg/hr intraoperative infusion. D/C at closure Avoid If QTc >0.45 Ketamine 0.2mg/kg one dose IV Lidocaine 1mg/kg bolus followed by 0.5-1mg/kg infusion stop at the end of surgery. Consider lidoderm patch Bilateral TAP Blocks either continuous or Single Injection ml % Ropivacaine

34 Intraoperative Period Fluid Management Should be Goal Directed by dynamic flow related parameters Cardiac Output, Stroke Volume, Stroke Volume Variation with Ventilation, pulse pressure variations, and pleth variability index. Equipment: Arterial line related such as LiDCO, PiCCO, FloTrac, or Pleth technology, Esophageal Doppler, TEE, ScVo2, and others. Not necessary the amount of fluids but the timing will change with these parameters Improved Outcomes with Goal Directed Therapy Shorter length of stays and lower complication rates Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc /13/

35 Intraoperative Fluid Management Low Risk Patients ASA 1-2 Restrictive Protocol ELECTIVE ONLY! Non-complicated colorectal procedures on relatively healthy adults Non-Invasive Cardiac Output Monitoring Mechanical Ventilation 6-8ml /kg Especially if utilizing ventilation variations (SVV or PVI) 10/13/2018 Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc

36 Fluids D5LR, LR, D5Normosol 3ml/kg/hr Crystalloids not Saline Goal is to reduce Salt Loading Intraoperative Fluid Management Low Risk Patients MAP < 65mmHg 250ml of Crystalloids or colloids like voluven NOT NS after two boluses and not improved start phenylephrine EBL over 500ml replace with colloid 1:1 10/13/2018 Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc

37 Intraoperative Fluid Management Moderate Risk Patients without arterial line ASA 2 or 3 Blood loss expected <1,500ml PIV access 2 +- central line with or without SCVO2. Mechanical Ventilation 6ml/kg Non-Invasive cardiac monitoring Esophageal Doppler, Cheetah, PVI, etc. Cardiac Optimization and fluid management

38 Intraoperative Fluid Management Moderate Risk Patients without arterial line Fluids D5LR, LR, D5Normosol 3ml/kg/hr Crystalloids not Saline Goal is to reduce Salt Loading MAP < 65mmHg 250ml of Crystalloids or colloids like voluven NOT NS after two boluses and not improved start phenylephrine EBL over 500ml replace with colloid 1:1 10/13/2018 Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc

39 10/13/2018 Intraoperative Fluid Management High Risk Patients with Arterial Line ASA 3 or 4 Blood loss expected 1,500 or more. PIV access 2 plus central line with SCVO2? Arterial line Placement Mechanical Ventilation 6ml/kg Non-Invasive cardiac monitoring Esophageal Doppler, FloTrac, LiDCO, PiCCO, TEE Cardiac Optimization and fluid management Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc

40 Fluids D5LR, LR, D5Normosol 3ml/kg/hr Crystalloids not Saline Goal is to reduce Salt Loading Intraoperative Fluid Management High Risk Patients with Arterial Line MAP < 65mmHg 250ml of Crystalloids NOT NS after two boluses and not improved start phenylephrine EBL over 500ml replace with colloid 1:1 Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc /13/

41 Cardiac Optimization Improved Cardiac Performance: Increased SV by > 10% from fluid bolus Maximize Cardiac performance and delivery of oxygen SCVO2 or SVO2 are you meeting the demand Titration of Vasopressors or Inotropic therapies

42 Enhanced Recovery Pathway: Elective Laparoscopic Hand Assisted Colorectal Cases *Contraindications: Oral Carbohydrate (AM of Surgery): A1c>6.5, BMI>40, neuropathy, gastro paresis, uncontrolled GERD, large bowel prep Scopolamine: History of Glaucoma, urinary retention, psychiatric Lidocaine and Magnesium: QTC>0.45 Esmolol: SINUS BRADYCARDIA, heart block greater than first-degree, sick sinus syndrome, IV verapamil therapy, or pulmonary HTN

43 Continuous Bilateral Transverse Abdominis Plane Blocks Decrease Opioid Consumption by 47 Percent Following Laparoscopics Colorectal Surgery E. Buckley, M. Burns, T. Hickey, A. A. Taylor, & D. Voight Phelps County Regional Medical Center Rolla, Missouri USA Webster University St. Louis, Missouri USA INTRODUCTION: The reduction of opioids during the postoperative period is the focus of most enhanced recovery protocols. Many of these protocols for laparoscopic colorectal surgery utilize truncal blocks such as single injection bilateral transversus abdominis plane blocks instead of low thoracic epidurals. OBJECTIVE(S) The purpose of this study was to evaluate the effectiveness of single injection versus continuous abdominis plane blocks on postoperative opioid consumption for 48 hours METHOD(S) A retrospective chart review of elective laparoscopic colorectal procedures was performed (n=34). All patients received intrathecal morphine 200mcg, similar postoperative opioid orders, alvimopan 12 mg PO, and either bilateral single injection transverse abdominis plane blocks with 15ml of 0.5% ropivacaine on each side or continuous bilateral transverse abdominis plane blocks with the same initial bolus. Then a 0.2% ropivacaine infusion at 5ml/hr is started bilaterally for 48 hours. All opioid data was collected and converted to IV morphine equivalents utilizing GlobalRPh program. RESULT(S) The continuous TAP block group received 47% less opioids over 48 hours (p=0.031). This significant decrease was noted during the postanesthesia care unit (p= 0.049) and within the first 24 hours (p=0.006). The opioid consumption for the following 24 hours was not statistically significant (p>0.05). Contact Information: mburns@pcrmc.com CONCLUSION(S) Continuous transverse abdominis plane blocks significantly decreased the opioid consumption during the postoperative period. The substitution of this modality for low thoracic epidurals could assist in decreasing opioid related complications as well as known difficulties with low thoracic epidural such as systemic hypotension, foley catheter placement, delayed ambulation, and interference with anticoagulation. REFERENCES A. Feldheiser. et. al. Enhanced recovery after surgery for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiology Scand 2016 Mar; 60(3):

44 Next Procedure- Outpatient Shoulder Arthroscopic Repair of Rotator Cuff Prior to ERAS 1:4 chance of being admitted or Emergency room visit the day of surgery. Respiratory Complications Nausea/Vomiting Pain

45 Enhanced Recovery Pathway: Shoulder Arthroscopic Procedures *Contraindications: Esmolol: SINUS BRADYCARDIA, heart block greater than first-degree, sick sinus syndrome, IV verapamil therapy, or pulmonary HTN

46 Low volume continuous ISB. Infuse 0.2% ropivacaine 5 ml/hour with 2 ml/hour PCA until POD 3 PREOPERATIVE Incentive Spirometry 7 days prior, 10 times/hour while awake

47 INTRAOPERATIVE Replace induction opioid dose with esmolol* 0.5 mg/kg. Infuse at 5-30 mcg/kg/min or bolus with mg/kg if hypertensive/tachycardic with surgical stimulation. 8 mg dexamethasone prior to incision 4 mg ondansetron prior to close 30 mg ketorolac prior to close OR, if contraindicated, 1000 mg IV acetaminophen with induction If patient emerges in pain, administer hydromorphone IV PRN

48 POSTOPERATIVE Apply Advance Administer Administer Apply ICE to site ASAP Advance diet as soon as patient tolerates Administer PO pain medications as first line therapy for post operative pain Administer hydromorphone for pain that exceeds above interventions

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54 TOTAL JOINT ARTHROPLASTY 01 JOINT CAMP 02 PLANNED SAME DAY TOTAL SHOULDERS AND KNEES 03 GOAL AMBULATION IN THE PACU

55 Enhanced Recovery Pathway: Total Joint Replacement *Contraindications: Esmolol: SINUS BRADYCARDIA, heart block greater than first-degree, sick sinus syndrome, IV verapamil therapy, or pulmonary HTN TXA: PE or DVT within 12 months of surgery, DVT or PE history treated with anticoagulation, congenital thrombophilia, cardiac stent/ischemic stroke w/i 12 months, creatinine >1.5, severe ischemic heart disease, history of thromboembolic or vascular disease, DIC

56 SA: Low volume continuous ISB. Infuse 0.3% ropivacaine 5 ml/hour with 2 ml/hour PCA until POD 3 THA: Single injection fascia iliaca nerve block with 15 ml 0.5% ropivacaine PREOPERATIVE TKA: Single injection I-Pack block, single injection lateral cutaneous nerve block, continuous Adductor Canal block. Infuse 0.2% ropivicaine 5ml/hour with 2 ml/hour PCA until POD 2 If CR<1.5 and no CHF, PREOP 10 mg oxycontin, 600 mg gabapentin, 200 mg celebrex Incentive Spirometry 7 days prior, 10 times/hour while awake

57 Continuous Adductor Canal Single Injection Lateral Femoral Nerve of the Thigh. Single Injection I-PACK Blocks Infiltration area between the Popliteal Artery and Capsule of the knee. LSU Medical Center 2017 reported a study supporting this technique on 106 patients. They compared Continuous Femoral Nerve block with I-PACK vs Just Femoral vs Continuous Adductor with I-PACK Continuous Adductor with I-Pack less opioids, shorter length of stay, and longer gait distance POD#1. Thobhani S, Scalercio L, Elliott C. et al. Novel regional techniques for total knee arthroplasty promote reduced hospital length of stay: An analysis of 106 patients: Ochsner Journal 2017;17 (1):

58 INTRAOPERATIVE Replace induction opioid dose with esmolol* 0.5 mg/kg. Infuse at 5-30 mcg/kg/min or bolus with mg/kg if hypertensive/tachycardic with surgical stimulation. 8 mg dexamethasone prior to incision 4 mg ondansetron prior to close mg ketorolac prior to close OR, if contraindicated, 1000 mg IV acetaminophen with induction TXA*: THA & TSA 2 grams prior to incision; TKA 1 gram prior to incision & 1 gram after tourniquet deflated If patient emerges in pain, administer hydromorphone IV PRN

59 Apply ICE to site ASAP Advance diet as soon as patient tolerates POSTOPERATIVE Administer PO pain medications as first line therapy for post operative pain Administered hydromorphone for pain that exceeds above interventions

60 Self Assessment- Honest Feedback

61 More Feedback

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63 Elective Cesarean Sections <4mg Morphine 1 st 24 hours Spinal anesthesia/analgesia with 0.75% bupivacaine in 8.25% dextrose and 100 mcg Duramorph Bilateral single injection TAP blocks with 15 ml 0.5% ropivacaine Ketorolac 30 mg IV in OR and 15 mg q 6 hours for 24 hours. Central monitoring of ETCO2 and Pulse Oximeter for 24 hours

64 Future ERAS

65 References Enhanced Recovery for Major Abdominopelvic Surgery. Gan T, Thacker J, Miller T, Scott M, & Holubar S 1 st ed The American Society of Enhanced Recovery For orders: or Gustafsson U. O., Scott M. J., Schwenk, W., et. al. Guidelines for perioperative care in elective colonic Surgery: Enhanced Recovery After Surgery (ERAS ) Society Recommendations. 2013; 37 (2): Thobhani S, Scalercio L, Elliott C. et al. Novel regional techniques for total knee arthroplasty promote reduced hospital length of stay: An analysis of 106 patients: Ochsner Journal 2017;17 (1):

66 The End