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ERAS.pptx
- 2. 23-03-2023 2 2 ENHANCED RECOVERY AFTER SURGERY IN RADICAL CYSTECTOMY DR YAAM KUMAR 1st YEAR DrNB 23-03-2023 2
- 3. 23-03-2023 3 ERAS • Also referred as “enhanced recovery programs” or “fast-track protocols” • They are evidence-based, collaborative perioperative care pathways designed to improve recovery after major surgical procedures. 23-03-2023 3
- 4. 23-03-2023 4 • AIM - To maintain preoperative organ function and reduce the body’s stress response after surgery. • ERAS protocols contain preoperative, intraoperative, and postoperative components that include patient counseling, nutritional optimization, standardized analgesic and anesthetic regimens, and early mobilization (Melnyk et al., 2011) 23-03-2023 4
- 5. 23-03-2023 5 • ERAS – first described by Henrik Kehlet in 1990. • Meta-analyses of studies of colorectal surgery patients have provided evidence for reduction of complications (50%) and hospital stay (2.5 days) by application of ERAS pathways (Varadhan et al., 2010). • This has led to adoption of ERAS protocols in many surgical Specialties including gynecologic,thoracic,vascular, pediatric, and orthopedic surgery, and most recently urology 23-03-2023 5
- 6. 23-03-2023 6 • Evidence based multimodal approach focused on peri- operative period • Improve patient recovery after surgery - Modifyphysiologicandpsychologicalresponse - Enabledischargehome earlier - Without compromisingsafetyandwellbeing • Several meta-analyses have shown accelerated recovery and decreased hospital stay with ERASin colorectal surgery. 23-03-2023 6
- 7. 23-03-2023 7 • In urology, the best studied ERAS protocols are in patients undergoing radical cystectomy and urinary diversion. 23-03-2023 7
- 8. 23-03-2023 8 • In 2010, the ERAS Society was founded and headquartered in Kista, Sweden. • The mission of the ERAS Society is to “develop perioperative care and to improve recovery through research, audit education and implementation of evidence-based practice.” • The Society website (http://www.erassociety.org/) offers procedure- specific guidelines, useful information, and resources related to enhanced recovery 23-03-2023 8
- 9. 23-03-2023 9 • The ERAS Society, the main society dedicated to the study of multimodal perioperative care pathways, has published guidelines that include 22 ERAS recommendations for patients undergoing radical cystectomy (Cerantola et al., 2013). • Majority of these recommendations are extrapolated from colorectal surgery literature without any direct evidence from the cystectomy population supporting their use. • Only 7 of the 22 ERAS recommendations, as outlined by the ERAS Society guidelines are backed by direct evidence from urology patients (Cerantola et al., 2013) 23-03-2023 9
- 13. 23-03-2023 13 Bladder Cancer Invasivebladder canceradisease of the elderly - Most patientsare 65yrs or older - Increasing %are 80+yrs Multiple medicalconditions Cumulative cigarette smokeexposure - Cardiacdisease - Decreased pulmonary function Up to 1/3receiveneoadjuvantchemotherapy
- 14. 23-03-2023 14 RadicalCystectomy Among the most complex urologic operations - Associated with considerable morbidity and prolonged inpatientstay LOSremainsin the 8-9 day rangeandis - the most reported quality indicator for RC
- 15. 23-03-2023 15 Traditional Care Surgeryisplanned ‘assoonaspossible’ - No training or conditioning Bowel prep (mechanicalandantibiotic) NPO(clear liquids only for preop1-2 days) Compensatory overhydration at onset of case - aggressivehydration during case–fluid overload NGTand NPO untilflatus Opioid analgesia - Limiting mentalacuity and mobility
- 16. 23-03-2023 16 Traditional Hospital Course Typical stay ~10days inUS* ~60%complication rate (15%high-grade complications) ~30%hospital readmissionrate *15-20daysin Europe/Asia v
- 18. 23-03-2023 18 Preoperative EnhancedRecovery Framework Optimization of medicalco-morbidities Smoking cessation NutritionAssessment - Evenshort termdietary modification helpful - Decrease alcohol intake Prehabilitation - Physical conditioning, even 1week ishelpful
- 19. 23-03-2023 19 Preoperative EnhancedRecovery Framework Written and oral pre-admission information describing: What will happensduring hospitalization What they shouldexpect - Length of stay - Home plan Whowill be at homewith you after discharge? Their role in the preparation and recoveryprocess
- 20. 23-03-2023 20 Intra-operative Enhanced Recovery Framework Efficient and expeditioussurgery Smaller incision Lessbowel manipulation Minimization ofblood loss and transfusion Non-narcotic analgesiaintraoperatively Instillation of local anesthetic at incision sites
- 21. 23-03-2023 21 GIRecovery is an Important Driver for Length of Stay and Readmission Delayed GIrecovery (POI, “ileus”) is the most common causefor prolonged hospital stay after radical cystectomy - Rate of POI:12and25% POI-related increased LOScontributes to morbidity - Increaserisk of secondaryclinicalconsequences(eg nosocomialinfections,readmissions) POI adds substantive cost burden to the healthcare system
- 22. 23-03-2023 22 Enhanced Recovery Framework Avoid intense bowelpreparation Avoid NGtubes Pharmacological prophylaxis of postoperative nausea orvomiting Enforcedearlyenteral feeding diet POD#1 Liberal useoflaxatives Alvimopan
- 23. 23-03-2023 23 Take home messages ERASFramework - BeginsPRIORto the actual admission - Communicate expectations Identify and treatcomorbidities Physical Conditioning Carbohydrate loading
- 24. 23-03-2023 24 Take home messages GIoptimization - Avoid bowel prep - Minimize bowel handlingintra-op - No NGtubes Reduceeffects ofopioids - Alvimopan –start prior to surgery - Non narcotic useintra-operative - Long acting localanesthetic
- 25. 23-03-2023 25 Take home messages SurgeonFactors - Expeditious surgery - Minimize blood loss EarlyMobilization - Feedearly - Walkearly
- 26. 23-03-2023 26 Take home messages Earlydetection, screening & prevention - Thefirst 2 weeksafter discharge are critical
- 27. 23-03-2023 27 ERAS(Enhanced Recovery After Surgery) A multidisciplinary approach involving surgeons, anesthesiologists, nurses, dieticians, and allied health professionals is one of the key paradigm shifts that is now neededto optimise recoveryof our patients .
- 28. 23-03-2023 28 Framework of Enhanced Recovery Pre operative • Counseling • Teaching(written and verbal) • Expectations • Discharge plan • Stomateaching • Stomamarking • Optimization • Lungs • Cardiac • Prehabilitation • Nutrition • Carbloading • No prolongedfast • No bowelprep • VTE prophylaxis Post operative • Paincontrol • Avoidance of opioids and toxicity • Early mobilization • Early oralnutrition • Nutrition drinks • Avoid salt andwater overload • IleusControl • Prevention ofN/V • No NGtubes • No aggressivebowel regimen • VTE prophylaxis • Early follow-up Enhanced Recovery Intra operative • Avoidance of saltand water overload • Maintenance of normothermia • Localanesthesia • Antibiotics accordingto AUA BestPractices • Alvimopan(FDAapproved)