An enhanced recovery protocol [ERP] is a set of standardized perioperative procedures and practices that are applied to all patients undergoing a given elective surgery. In general, these protocols are not intended for emergent cases, but components of them certainly could apply to the urgent patient.
ERP’s were associated with a reduction in overall complications and length of stay when compared with conventional perioperative patient management – also associated with reduced healthcare costs and improved patient satisfaction.
- A preoperative discussion of milestones and discharge criteria should typically be performed with the patient before surgery. Standardized discharge criteria have been defined which states that patients are fit for discharge when there is tolerance of oral intake, recovery of lower GI function, adequate pain control with oral analgesia, ability to mobilize, ability to perform self-care, no evidence of complications or untreated medical problems, adequate post-discharge support and patient willingness to leave the hospital
PREADMISSION NUTRITION AND BOWEL PREPARATION
- A clear liquid diet may be continued up to 2 hours before general anaesthesia
- Carbohydrate loading should be encouraged before surgery in non-diabetic patients
- Mechanical bowel preparation plus oral antibiotics are the preferred preparation and are associated with reduced complication rates
- Prehabilitation before elective surgery may be considered for with multiple co-morbidities or significant deconditioning – this aims to augment functional capacity before a surgical procedure with the intent to minimize the postoperative morbidity and accelerate postsurgical recovery.
SURGICAL SITE INFECTION
- A bundle of measures should be in place to reduce surgical site infection – this includes mechanical bowel preparation with oral antibiotics, intravenous prophylactic antibiotics within 1 hour of incision, standardization of preparation with chlorhexidine. Operative measures include use of a wound protector, gown and glove change before fascial closure, use of a dedicated wound closure tray and limited operating room traffic. Postoperative measures include removal of sterile dressings within 48 hours and daily washings of the incision with chlorhexidine. Patient education, euglycemia and normothermia also are components of this. Other measures that have been included are a reduction in intraoperative IV fluid use, supplemental oxygen, double gloving, smoking cessation, Penrose drains for high BMI, pulse lavage of subcutaneous tissue and silver dressings for 5 days postoperative.
- A multimodal, opioid-sparing pain management plan should be used and implemented before the induction of anaesthesia. Multiple studies have shown that minimizing opioids is associated with the earlier return of bowel functions and shorter length of stay. One of the simplest techniques is to schedule narcotic alternatives, such as oral acetaminophen, NSAID’s and gabapentin rather than giving them on an as-needed base. Systemic perioperative gabapentinoids, ketamine and alpha2-agonists have also been used to improve analgesia. Limited data demonstrate that the transversus abdominis plane block with a local anaesthetic has been associated with decreased length of stay compared with systemic opioids in laparoscopic colorectal surgery.
- Thoracic epidural analgesia is recommended for open colorectal surgery but not for routine use in laparoscopic surgery.
PERIOPERATIVE NAUSEA AND VOMITING
- Antiemetic prophylaxis should be guided by preoperative screening for risk factors for postoperative nausea/vomiting.
- Preemptive multimodal antiemetic prophylaxis should be used in all at-risk patients to reduce PONV. Combination therapy is the best approach in high-risk patients. A common intervention for patients at high risk is the administration of dexamethasone at the induction of anaesthesia and ondansetron at the emergence of anaesthesia. Additional strategies include the use of TIVA, IV acetaminophen and gabapentin.
INTRAOPERATIVE FLUID MANAGEMENT
- A maintenance infusion of crystalloids should be tailored to avoid excess fluid administration and volume overload. A maintenance infusion of 1.5-2ml/kg/h of balanced crystalloid solution is sufficient to cover the needs derived from salt-water homeostasis during major abdominal surgery while limiting substantial postoperative weight gain [>2.5kg/d] which is associated with increased morbidity and prolonged hospital stay.
- Balanced chloride restricted crystalloid solutions should be used as maintenance infusion in patients undergoing colorectal surgery.
- In high-risk patients and in patients undergoing major surgery, the use of goal-directed fluid therapy is recommended.
- A minimally invasive surgical approach should be used whenever the expertise is available and appropriate. There is high-quality evidence that, in appropriate cases, when performed by properly trained personnel, laparoscopic treatment of colorectal conditions is beneficial compared to open surgery.
- The routine use of intra-abdominal drains and nasogastric tubes for colorectal surgery should be avoided.
- Early and progressive patient mobilization is associated with shorter length of stay. Complications of prolonged immobility include skeletal muscle loss and weakness, atelectasis, insulin resistance, thrombo-embolic disease and decreased exercise capacity.
- Patients should be offered a regular diet immediately after elective colorectal surgery. Multiple randomized studies demonstrated that early [<24h] feeding accelerated GI recovery and decreased the hospital length of stay. The rate of complications and mortality were also decreased with early feeding. The factor related to failure of early feeding was identified as blood loss during the operation in open cases whereas age younger than 50, surgery performed by colorectal surgeons and use of laparoscopic surgery were associated with success.
- Sham feeding [chewing sugar free gum for 10 minutes 3-4 timers per day] after colorectal surgery is safe and results in small improvements in GI recovery and may be associated with a reduction in hospital stay.
POSTOPERATIVE FLUID MANAGEMENT
- Intravenous fluids should be discontinued in the early postoperative period after recovery room discharge. Because of the negative impact of fluid excess on clinical outcomes, IV fluids should be discontinued in the early postoperative period and clear fluids [>1.75l/d of water] encouraged as tolerated soon after surgery. IV fluids should be administered only when deemed clinically necessary. To prevent excessive fluid administration, daily postoperative weight gain should be monitored and weight gain more than 1-2kg avoided.
- Urinary catheters should be removed within 24 hours of elective or upper rectal resection when not involving a vesicular fistula.
- Urinary catheters should be removed within 48 hours of midrectal/lower rectal resections