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    Enhanced Recovery After Surgery (ERAS) : Another MYTH or PARADIGM Shift!

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    The document discusses Enhanced Recovery After Surgery (ERAS), a multidisciplinary approach to improve surgical recovery quality by lessening physiological impact. It recommends pre, peri, and postoperative best practices like prehab, tight glycemic control, and early nutrition/mobility to reduce complications versus just speeding discharge. ERAS emphasizes patient education and compliance with its integrated protocol.

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    Enhanced Recovery After Surgery (ERAS) : Another MYTH or PARADIGM Shift!

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    Mahmoud Ibrahim
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    The document discusses Enhanced Recovery After Surgery (ERAS), a multidisciplinary approach to improve surgical recovery quality by lessening physiological impact. It recommends pre, peri, and postoperative best practices like prehab, tight glycemic control, and early nutrition/mobility to reduce complications versus just speeding discharge. ERAS emphasizes patient education and compliance with its integrated protocol.

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    The document discusses Enhanced Recovery After Surgery (ERAS), a multidisciplinary approach to improve surgical recovery quality by lessening physiological impact. It recommends pre, peri, and postoperative best practices like prehab, tight glycemic control, and early nutrition/mobility to reduce complications versus just speeding discharge. ERAS emphasizes patient education and compliance with its integrated protocol.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    60 views33 pages

    Enhanced Recovery After Surgery (ERAS) : Another MYTH or PARADIGM Shift!

    Uploaded by

    Mahmoud Ibrahim
    The document discusses Enhanced Recovery After Surgery (ERAS), a multidisciplinary approach to improve surgical recovery quality by lessening physiological impact. It recommends pre, peri, and postoperative best practices like prehab, tight glycemic control, and early nutrition/mobility to reduce complications versus just speeding discharge. ERAS emphasizes patient education and compliance with its integrated protocol.

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    of 33

    ENHANCED RECOVERY AFTER

    SURGERY
    (ERAS)

    Another MYTH or PARADIGM shift!

    Husain Abbas, MD FACS FASMBS


    DISCLOSURES

    NONE
    HEALTHCARE SPENDING

    Source: Organisation for Economic Co-operation and Development (2010), “OECD


    Health Data”, OECD Health Statistics
    HEALTHCARE SPENDING

    • 2015, U.S. health care spending increased 5.8 percent to reach $3.2
    trillion, or $9,990 per person
    • Overall share of the U.S. economy devoted to health care spending
    was
    • 17.8 percent in 2015
    • up from 17.4 percent in 2014
    HOW DO WE FARE?!
    WHERE DO WE SPEND THE MONEY

    Dental & Other


    services

    Nursing home Hospital Care


    & HHC
    Prescriptions
    Physician &
    Clinical Services
    HEALTHCARE SPENDING

    • Total healthcare spending $2.7 trillion in 2011. A little over 31 percent of that
    amount, or $814 billion, was spent on hospital services.

    • Hospital costs averaged $3,949 per day,


    • $15,734 per stay

    • Top three procedure (expense wise)-


    • Spinal fusion surgery ($11.26 billion)
    • Coronary angioplasty ($11 billion)
    • knee replacement surgery ($10.36 billion)
    OFFICE VISIT

    • 46 years obese female


    • 290 lbs (BMI 47)
    • Presents with right knee pain making it difficult to
    walk
    • Thinks if you can help to fix her knee she will
    lose her excess weight
    CO-MORBIDITIES MEDICATIONS
    • Osteoarthritis • Lantus
    • R knee replacement • Metoprolol
    • Awaiting for L knee • ARB
    replacement
    • Percocet
    • Chronic back pain
    • Tramadol
    • HTN
    • CPAP
    • HLP
    • Diabetes Mellitus
    • CAD
    OBESITY

    • Obesity is one of the biggest drivers of preventable chronic diseases and


    healthcare costs in the United States. Currently, estimates for these costs range
    from $147 billion to nearly $210 billion per year.1

    • Job absenteeism, costing approximately $4.3 billion annually 2 and with lower
    productivity while at work, costing employers $506 per obese worker per year.2,3

    1 Gates D et al. J Occ Envir Med, 50(1):39-45, 2008.


    2 Cawley J, Rizzo JA, Haas K. Occupation-specific Absenteeism Costs Associated with Obesity and Morbid Obesity. Journal of Occupational
    and Environmental Medicine, 49(12):1317?24, 2007.
    3 Gates D, Succop P, Brehm B, et al. Obesity and presenteeism: The impact of body mass index on workplace productivity. J Occ Envir Med,

    50(1):39-45, 2008.
    OBESITY IS A MAJOR CAUSE OF
    DIABETES

    • Nearly 30 million Americans have diabetes

    • $1 in $3 Medicare dollars is spent caring for people with diabetes

    • Diabetes and prediabetes cost America $322 billion per year

    • 86 million Americans have prediabetes

    • $1 in $5 health care dollars is spent caring for people with diabetes


    OBESITY IS A MAJOR CAUSE OF
    DIABETES
    Today -
    • 3,835 Americans will be diagnosed with diabetes

    • Diabetes will cause 200 Americans to undergo an amputation

    • 136 to enter end-stage kidney disease treatment

    • 1,795 to develop severe retinopathy that can lead to vision loss and
    blindness
    SURGICAL PATIENTS

    • More obese

    • Multiple comorbidities
    SICKER PATIENTS!
    • Multiple medications

    • Much more challenging


    ENHANCED RECOVERY AFTER SURGERY

    • Lessen the physiological impact of surgical intervention


    • It’s about the QUALITY of recovery rather than SPEED
    of discharge or LENGTH OF STAY
    • Multidisciplinary approach
    • Pre, per and post-operative (they are ONE process)
    • Lower post-operative complications and 30-days
    readmission rate
    • Compliance is a big issue!
    ENHANCED RECOVERY AFTER SURGERY

    • Multidisciplinary approach
    • Surgeon
    • Anesthesia
    • ERAS coordinator
    • Pre, peri and post-operative plan of care (ONE
    integrated process)
    PROCESS

    Clinic - Anesthesia
    Pre-OP Post-op &
    Initial and Home
    evaluation floor care
    Consult surgery

    Interactive team follow-up, compliance and analysis


    HOSPITALIZATION

    Ileus,
    distension &
    discomfort

    Analgesia
    (opioids) Procedure Limits
    mobility

    Pain
    Preoperative
    Element Recommendation
    Preoperative Patients should receive preoperative counseling
    information,
    education and MUST have the PATIENT BUY-IN
    counseling

    Prehabilitation and Although prehabilitation may improve functional recovery, there are
    Exercise insufficient data in the literature to recommend prehabilitation before
    bariatric surgery for the reduction of complications or length of stay

    Smoking and alcohol Tobacco smoking should be stopped at least 4 weeks before
    Cessation surgery. For patients with a history of alcohol abuse,
    abstinence should be strictly adhered to for at least
    2 years.
    Preoperative
    Element Recommendation

    Preoperative weight Preoperative weight loss should be recommended prior to bariatric surgery
    Loss Patients on glucose-lowering drugs should be aware of the risk of
    hypoglycemia

    Glucocorticoids 8 mg dexamethasone should be administered i.v., preferably 90 min prior to


    induction of anesthesia for reduction of PONV as well as inflammatory
    response
    Preoperative fasting Obese patients may have clear fluids up to 2 h and solids up to 6 h prior to
    induction of anesthesia.

    Carbohydrate loading While preoperative oral carbohydrate conditioning in patients undergoing


    major abdominal elective surgery has been associated with metabolic and
    clinical benefits
    Preoperative
    Element Recommendation
    Preoperative fasting Obese patients may have clear fluids up to 2 h and solids up to 6 h prior to
    induction of anesthesia.

    Carbohydrate While preoperative oral carbohydrate conditioning in


    loading patients undergoing major abdominal elective surgery has been associated with
    metabolic and clinical benefits, further data are required in morbidly obese
    patients.
    Perioperative
    Element Recommendations
    Perioperative Excessive intraoperative fluids are not needed to prevent rhabdomyolysis and
    fluid maintain urine output. Functional parameters, such as stroke volume variation
    management facilitate goal-directed fluid therapy and avoid intraoperative hypotension and
    excessive fluid administration. Postoperative fluid infusions should be
    discontinued as
    soon as practicable with preference given to use of the enteral route
    PONV A multimodal approach to PONV prophylaxis should be
    adopted in all patients
    Standardized The current evidence does not allow recommendation of
    anesthetic specific anesthetic agents or techniques
    protocol
    Airway Anesthetists should be aware of the specific difficulties in
    management managing bariatric airway

    Tracheal intubation remains the reference for airway


    management
    Perioperative
    Element Recomendations
    Ventilation Lung protective ventilation should be adopted for elective
    strategies bariatric surgery

    Patient positioning in an anti-Trendelenburg, flexed hip,


    anti- or beach chair positioning, particularly in the
    absence of pneumoperitoneum improves pulmonary
    mechanics and gas exchange
    Neuromuscular Deep neuromuscular block improves surgical performance
    block
    Ensuring full reversal of neuromuscular blockade improves
    patient recovery

    Objective qualitative monitoring of neuromuscular blockade


    improves patient recovery
    Monitoring of BIS monitoring of anaesthetic depth should be considered
    anaesthetic where ETAG monitoring is not employed
    depth
    Perioperative
    Element Recommendations

    Laparoscopy Laparoscopic surgery for bariatric surgery is recommended


    whenever expertise is available

    Minimal unnecessary tissue handling


    Nasogastric tube Routine use of nasogastric tube is not recommended
    postoperatively

    Abdominal There is insufficient evidence to recommend routine use of


    drainage abdominal drainage
    Postoperative
    Element Recommendation

    Postoperative Multimodal systemic medication and local anaesthetic infiltration techniques should be
    analgesia combined. Thoracic epidural analgesia should be considered in laparotomy
    Thromboprophylaxis Thromboprophylaxis should involve mechanical and pharmacological measures with
    LMWH. Dosage and duration of treatment should be individualised
    Early postoperative Protein intake should be monitored. Iron, vitamin B12 and
    nutrition calcium supplementation is mandatory

    Postoperative glycaemic and lipid control has to be strict in


    patients with diabetes
    Postoperative Obese patients without OSA, should be supplemented with oxygen prophylactically in head-
    oxygenation elevated or semi-sitting position in the immediate postoperative period

    Uncomplicated patients with OSA should receive oxygen supplementation in a semi-sitting


    position. Monitoring for possible increasing frequency of apnoeic episodes should
    be diligent. A low threshold for initiation of positive pressure support must be maintained in
    the presence of signs of respiratory distress
    Perioperative
    Element Recommendation

    Non-invasive positive Prophylactic routine postoperative CPAP is not recommended in obese patients without
    pressure ventilation diagnosed OSA

    CPAP therapy should be considered in patients with BMI [50 kg/m2, severe OSA or oxygen
    saturation B90 % on oxygen supplementation

    Obese patients with OSA on home CPAP therapy should use their equipment in the
    immediate postoperative period

    Patients with Obesity Hypoventilation Syndrome (OHS) should receive postoperative


    BiPAP/NIV prophylactically along with intensive care level monitoring
    ERAS IMPLEMENTATION IMPACT

    Malczak P, Enhanced Recovery after Bariatric Surgery: Systematic


    Review and Meta-Analysis. Obes Surg. 2017; 27(1): 226–235.
    ERAS IMPLEMENTATION IMPACT
    ERAS ECONOMIC IMPACT

    • However, only the reduction in primary LOS was significant. The net health
    system savings were estimated at $2 290 000 (range $1 191 000–$3 391 000), or
    $1768 (range $920–$2619) per patient1

    • The probability for the program to be cost-saving was 73%–83%1,2

    • In terms of ROI, every $1 invested in ERAS would bring $3.8 (range $2.4–$5.1)
    in return2

    1Walter CJ et al. Enhanced recovery in colorectal resections: a systematic review and meta-
    analysis. Colorectal Dis 2009;11:344–53
    2Nelson G, et al Cost impact analysis of Enhanced Recovery After Surgery program

    implementation in Alberta colon cancer patients. Curr Oncol. 2016 June;23(3):e221-227

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