ERAS: Enhanced Recovery After Surgery Christopher L. Wu, M.D. Professor of Anesthesiology The Johns Hopkins University; Baltimore, Maryland
Overview History and basic principles of ERAS Review published ERAS data Anesthesiology ERAS topics Goal-directed fluid therapy (GDFT) Multimodal analgesia Regional anesthesia-analgesia ERAS at Hopkins
History of ERAS Previously known as fast-track surgery Studies in 1990s (Kehlet Denmark) showed LOS for colon resection from 9-10 d 2 d Also known as enhanced recovery programs (ERP) ERAS : acronym started in 2001 (academic surgeons) Intent: develop optimal evidence-based perioperative care pathway to facilitate patient recovery Changed name from fast-track (implied focus on faster d/c only) to ERAS (focus on overall patient recovery) Br J Surg 1999;86:227-30 JPEN 2014;38:559-66
Philosophy of ERAS Traditional hospital works in silos need to be removed to optimize patient care One team may have little insight if the treatment they use for their purpose is beneficial hrs or days later Team taking over patient care may have little insight into what occurred before their part of the care process ERAS pathways designed everyone involved in the entire chain of events during patient s care True multidisciplinary effort: improves communication; allows team members to understand each other roles JPEN 2014;38:559-66
JPEN 2014;38:559-66
ERAS: General Goals Get patient back to normal preoperative function as quickly as possible Normal gastrointestinal function Pain control Mobilization Minimize complications Improve patient experience
ERAS: Basic Principles Multidisciplinary and collaborative approach Optimize perioperative nutrition Standardized perioperative anesthestic plan to minimize pain/opioid usage/stress response Early mobilization and oral intake Patient education and participation
Clin Nutr 2005;24:466-77
Preoperative Information, education and counseling Medical optimization Standardized bowel preparation Preoperative fasting and carbohydrate treatment Preanesthetic medication Prophylaxis against thromboembolism World J Surg 2013;37:259-84
Intraoperative Antimicrobial prophylaxis and skin preparation Standardized anesthetic protocol Multimodal approach to PONV prophylaxis Laparoscopy and modifications of surgical access (if applicable) Postoperative nasogastric tubes should not be used routinely (removed at end of surgery) Prevent intraoperative hypothermia Optimize perioperative fluid management World J Surg 2013;37:259-84
Postoperative Urinary drainage (limit to 1-2 days) Prevention of postoperative ileus Multimodal analgesia minimize opioids Perioperative nutritional care Postoperative glucose control Early mobilization World J Surg 2013;37:259-84
Does ERAS Work? Several meta-analyses of existing RCTs to suggest that ERAS (vs. traditional care) implementation will: Length of hospital stay (LOS) Complication rate Urinary tract infection Pneumonia, respiratory complications Cardiovascular complications No difference in mortality or readmission rate Cochrane Data Syst Rev 2011: CD007635 World J Surg 2014;38:1531-41 Int J Colorectal Dis 2012;27:1549-54
Decrease in Length of Stay World J Surg 2014;38:1531-41
Decrease in Respiratory Complications World J Surg 2014;38:1531-41
Decrease in UTI Yang D, Grant M et al (submitted)
Decrease in Cardiovascular Complications World J Surg 2014;38:1531-41
Decrease in Morbidity World J Surg 2014;38:1531-41
No Difference in Readmission World J Surg 2014;38:1531-41
No Difference in Mortality Int J Colorectal Dis 2012;27:1549-54
Anesthesiology ERAS Topics Goal-directed fluid therapy Anesthesiology providers have generally given too much IV fluids intraoperatively Multimodal analgesia Concurrent use of non-opioid analgesic agents will result in additive/synergistic analgesia while providing an opioid-sparing effect Regional anesthesia-analgesia Local anesthetic based technique may provide superior analgesia and physiologic benefits to facilitate patient recovery
Goal-directed Fluid Therapy Excessive IV crystalloids cardiac/pulmonary fxn, tissue oxygenation (SSI), paralytic ileus ERAS fluid management continuum through the pre-/intra- /post-operative phases (TE Miller, Duke) Preoperative: to OR in a hydrated and euvolemic state Avoid prolonged fasting; carbohydrate drink 2-3 h before surgery Intraoperative: maintain central euvolemia, avoid excess NaCl Individualized fluid management plan using balanced crystalloid solution (LR) to provide maintenance fluid therapy. Low-risk patients/surgery = "zero-balance" probably sufficient Higher risk patients/major surgery = consider GDFT Br J Anaesth 2002;89:622-32 Can J Anaesth 2015;62:158-68
Goal-directed Fluid Therapy Meta-analysis of 13 RCT (1399 patients) GDFT = first bowel motion (p=0.02), oral intake (p= 0.03), PONV (p = 0.01) GDFT = more effective outside ERAS, colorectal patients RTC (n = 100): GDFT vs. routine care GDFT = SV/CO, LOS (mean 5 vs 7 days, p=0.03), earlier oral intake of solid food (p=0.01) Meta-analysis (29 RCTs): preemptive hemodynamic intervention 4805 patients with an overall mortality of 7.6% Preemptive HD mortality (OR = 0.48 [0.33-0.78], p=0.0002), surgical complications (OR = 0.43 [0.34-0.53], p<0.0001) Br J Surg 2015;102:577-86 Anesthesiology 2002;97:820-6 Anesth Analg 2011;112:1392-402
Br J Surg 2015;102:577-86
Multimodal Analgesia Optimal pain control in ERAS is critical to facilitate recovery Multimodal analgesia (improve pain control, opioid-related side effects) is a key component of most ERAS programs Acetaminophen, NSAIDs, NMDA antagonists, local anesthetics, gabapentanoids, alpha-2 agonists, glucocorticoids Opioids sedation, PONV, urinary retention, ileus, RD Combining acetaminophen and NSAID superior analgesia compared with either drug alone Meta-analysis (21 RCTs, 1909 patients) Pain intensity 35% and 38% less for the combination versus acetaminophen alone and NSAID alone, respectively Can J Anaesth 2015;62:203-18 Anesth Analg 2010;110:1170-9
Single-Dose Analgesics: >50% Relief for Moderate-Severe Postoperative Pain Drug Mean NNT 95% CI Celecoxib PO 400mg 2.1 1.8-2.5 Codeine 60mg/Acetam PO 1000mg 2.2 1.7-2.9 Oxycodone PO 15mg 2.4 1.5-4.9 Ibuprofen PO 400mg 2.5 2.4-2.7 Ibuprofen PO 200mg 2.7 2.5-2.9 Meperidine IM 100mg 2.9 2.3-3.9 Morphine IM 10mg 2.9 2.6-3.6 Ketorolac IM 30mg 3.4 2.5-4.9 Celecoxib PO 200mg 3.5 2.9-4.4 Acetaminophen PO 1000mg 3.8 3.4-4.4 Tramadol PO 100mg 4.8 3.4-8.2 http://www.medicine.ox.ac.uk/bandolier/booth/painpag/acutrev/analgesics/leagtab.html
Regional anesthesia-analgesia Neuraxial (epidural, spinal) or peripheral (TAP, paravertebral, wound infiltration) blocks/catheters TAP block meta (10 RCTs, 633 subjects): TAP vs. control TAP block: pain at rest at 4 and 24 h, postoperative opioid consumption Preoperative (vs. postoperative) TAP block early pain, opioid consumption Analgesic efficacy of wound catheters (infusion of LA via catheters placed in surgical wounds) is uncertain Meta-analysis (32 RCTs): no difference in side effects or analgesia at rest or on activity, except in OB-GYN patients Morphine consumption, wound breakdown, LOS (p=0.04) Anesth Analg 2014;118:454-63 Acta Anaesthesiol Scand 2011;55:785-96
Anesth Analg 2014;118:454-63
Pain at rest-24 h Pain at rest-48 h Acta Anaesthesiol Scand 2011;55:785-96
Role of Epidural in ERAS? TEA superior analgesia, some pulmonary/cardiac morbidity, facilitate earlier return of GI function Overall benefits of TEA in laparoscopic procedures uncertain Meta-analysis of 7 RCTs (n=378): epidurals vs. alternative analgesic methods No significant difference in complication rate (OR=1.14 [0.49, 2.64], p=0.76) or LOS; EA faster return of GI fxn, pain scores Meta-analysis (6 RCTs): epidural analgesia on laparoscopic colorectal surgery TEA = first bowel motion (p=0.02) and pain scores (p=0.04) but no difference in LOS hospital, OR time, side effects JAMA Surg 2014;149:1224-3 Surg Endosc 2013;27:2581-91
ERAS at Hopkins (Anesthesiology) Goal: normal function as soon as possible Superior analgesia to facilitate recovery Minimize analgesic (opioid) side effects Short-term goals: LOS/pain, satisfaction Long-term goal: preservation of perioperative immune function: SSI/cancer recurrence Perioperative period creates a vulnerable period of immunosuppression for our surgical patients
Perioperative Period: High Risk Brain Beh Immun 2007;21:881-7
ERAS at Hopkins (Anesthesiology) Multiple systematic/literature reviews to examine available evidence for various aspects of care Incorporate appropriate evidence to meet both shortterm and long-term goals Create a preliminary pathway feedback from ERAS anesthesiology members Pathway trial further modifications based on clinical experiences Continued modification of pathway: new evidence or clinical experience warrants discussion/modification
ERAS at Hopkins (Anesthesiology) For open procedures = EA + TIVA For lap. procedures = TIVA + IV lidocaine + TAP Preserve immune fxn: avoid opioids, inhalation agents; ketamine, blood transfusions, hypothermia Epidural analgesia: integral part of ERAS pathways Superior analgesia vs. opioids Faster return of gastrointestinal function Attenuation of neuroendocrine stress response Preserve immune function/ opioid use
Epidural Anesthesia & Immunosuppression Eur J Canc Prevent 2008;17:269-72
Preoperative (Hopkins) Preoperative holding area (day of surgery) Oral celebrex (200 mg) Oral gabapentin (600 mg) Oral acetaminophen (1000 mg) Scopolamine patch (avoid dexamethasone) Insertion of thoracic epidural catheter (open cases)
Standardized Anesthetic (Hopkins) GOALS: maintain normothermia; avoid blood tnxs; minimize hypotension/hypoxia; maintain normocarbia Epidural anesthesia + TIVA (propofol) TEA: 2% lidocaine w/ 1:200K epi as bolus ( 10ml) to obtain T4 level + infusion of 2% lidocaine (no epinephrine) at 4-6ml/hr If no epidural, TIVA + IV Lidocaine gtt Adjuvants Acetaminophen 1gm IV x1 (if not given preop) Ketorolac 30 mg IV at end of case ( 15 mg IV for age >75) Ondansetron 8 mg IV 30 min prior to end of case
Postoperative (Hopkins) When NPO: PCEA: 0.0625% bupivacaine only (no fentanyl) Continue 1 day after tolerating oral intake/analgesics Assuming no contraindications Acetaminophen 1 gm IV/PO q8h Ketorolac 15-30 mg IV q6h or ibuprofen 400 mg PO q6h Breakthrough pain: hydromorphone IV prn
Postoperative (Hopkins) When taking PO: Acetaminophen 1000mg PO q8h Gabapentin 100 mg PO tid Ibuprofen 400 mg PO q6h Lidoderm patch Tramadol 50 mg PO q4-6h prn (before opioid) Breakthrough pain: prn opioid of choice
Hopkins CR ERAS: Results Prior to ERAS: Hopkins (major large and small bowel) mean LOS = 8.6 d (NSQIP: 10th decile) Colorectal ERAS started February 2014 Prelim analysis: colorectal d/c since 1/1/14 = median LOS of 2 days less than last 6 m of CY 2013 Equivalent of freeing up 4 additional beds every day Our own data analysis since 2/1/14 = Mean LOS = 5.3 d; median LOS = 4 d Marburg 2 patient satisfaction survey scores
Hopkins CR ERAS: LOS and Cost ERAS Patients 330 310 Baseline Net Savings Mean Length of Stay 5.3 days 7.2 days (-)1.9 days (26.4%)* *p<0.001 Variable Direct Cost $9,036 $10,933 (-1)$1,897 (17.3%)** **p=0.013 Armstrong Institute for Patient Safety and Quality J Am Coll Surg 2015;221:669-77
Early results: ERAS Expansion Liver Resection (Hopkins) Metric Pre ERAS Post ERAS Improvement Patients 42 56 Case Mix Index 2.6 2.5 (0.1) Length of 7.9 5.8 (2.1) Stay Cost $12,761 $10,450 ($2,311) Complications 9.5% 0.0% (9.5%) Readmissions 21.4% 19.6% (1.8%)
Hopkins CR ERAS: SSI Baseline 27% Hospital Target 15% Post-ERAS 6% Colorectal Operating Room CUSP ERAS Armstrong Institute for Patient Safety and Quality
Hopkins CR ERAS: Results Data from Johns Hopkins Hospital show a net savings of $400,000 in the first year of implementation Costs of Implementation: $552,783 Reduction in Direct Hospital Costs: $948,500 Net Savings: $395,717
NSQIP Report: 2015 Johns Hopkins Armstrong Institute for Patient Safety and Quality
Hopkins ERAS: Practical Considerations Attempted to develop an opioid-free ERAS pathway Opioids are ordered as a PRN (as needed) dose 50% pts will still receive opioids during their hospital stay but the overall amounts of opioids given are less With an accepted pathway, we were able to truly administer multimodal analgesia (ERAS ordersets) NSAIDs, acetaminophen, tramadol, gabapentin, epidural analgesia, lidocaine, opioid PRN for breakthrough pain Previously, some were reluctant to accept certain modalities (e.g., NSAIDs, gabapentin, epidural)
Not a rigid or fixed protocol: Final Thoughts Clinicians should feel free to do whatever they need to do to care for our patients Overall pathway continues to be modified based on updated evidence or clinician input Low volume ventilation, magnesium, acetaminophen Benefits: Focuses care around the patient Collaboration/communication among services true multidisciplinary effort Breaks down silos; staff morale; enhances SSI efforts