Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations (original) (raw)
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Background: The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Methods: Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English-language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. Results: This consensus statement demonstrates that anaesthesi-ologists control several preoperative, intraoperative and postoper-ative ERAS elements. Further research is needed to verify the strength of these recommendations. Conclusions: Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS â) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi-institutional prospective and adequately powered randomized trials.
Anesthetic Routines: The Anesthesiologist's Role in GI Recovery and Postoperative Ileus
Advances in Preventive Medicine, 2011
All patients undergoing bowel resection experience postoperative ileus, a transient cessation of bowel motility that prevents effective transit of intestinal contents or tolerance of oral intake, to varying degrees. An anesthesiologist plays a critical role, not only in the initiation of surgical anesthesia, but also with the selection and transition to effective postoperative analgesia regimens. Attempts to reduce the duration of postoperative ileus have prompted the study of various preoperative, perioperative, and postoperative regimens to facilitate gastrointestinal recovery. These include modifiable variables such as epidural anesthesia and analgesia, opioid-sparing anesthesia and analgesia, fluid restriction, colloid versus crystalloid combinations, prokinetic drugs, and use of the new peripherally acting mu-opioid receptor (PAM-OR) antagonists. Review and appropriate adaptation of these multiple modifiable interventions by anesthesiologists and their surgical colleagues will ...
Revista Dor, 2013
BACKGROUND AND OBJECTIVES: Postoperative pain in obese patients is a noxious event for their recovery delaying hospital discharge and increasing the chance of complications. This study aimed at determining pain frequency in the post-anesthetic care unit and at investigating factors associated to moderate to severe pain in obese patients submitted to gastroplasty, relating them to potential complications. METHODS: This is an observational and prospective study including 84 patients submitted to general anesthesia with sevoflurane for laparoscopic gastroplasty. Patients were evaluated in the post-anesthetic care unit for pain intensity by the verbal and numerical scale (Ramsay scale), presence of nausea, vomiting and respiratory complications. Logistic regression model was used to determine pain-related independent variables. RESULTS: There has been no pain at admission to the post-anesthetic care unit in 61.63% of patients. In the multivariate analysis, fentanyl as compared to sufentanil was the only independent factor associated to pain (OR 3.07-IC95% 1.17-6.4). There has been no difference between the type of opioid used and the presence of nausea and vomiting (p>0.05). Ramsay scale scores were not different between opioids used in the intraoperative period (p>0.05). CONCLUSION: The only independent factor associated to pain in the post-anesthetic care unit was the type of opioid used for anesthetic induction. Postoperative pain is still a frequent event affecting most patients, and analgesic protocols have to be implemented to minimize the effects that undertreated pain may induce.
Anesthesia and analgesia, 2017
The primary driver of length of stay after bowel surgery, particularly colorectal surgery, is the time to return of gastrointestinal (GI) function. Traditionally, delayed GI recovery was thought to be a routine and unavoidable consequence of surgery, but this has been shown to be false in the modern era owing to the proliferation of enhanced recovery protocols. However, impaired GI function is still common after colorectal surgery, and the current literature is ambiguous with regard to the definition of postoperative GI dysfunction (POGD), or what is typically referred to as ileus. This persistent ambiguity has impeded the ability to ascertain the true incidence of the condition and study it properly within a research setting. Furthermore, a rational and standardized approach to prevention and treatment of POGD is needed. The second Perioperative Quality Initiative brought together a group of international experts to review the published literature and provide consensus recommendati...
Canadian Journal of Surgery
Background: Patients with extreme obesity are at high risk for adverse perioperative events, especially when opioid-centric analgesic protocols are used, and perioperative pain management interventions in bariatric surgery could improve safety, outcomes and satisfaction. We aimed to evaluate the impact of intraperitoneal local anesthesia (IPLA) on enhanced recovery after bariatric surgery (ERABS) outcomes. Methods: We conducted a prospective double-blind randomized controlled pilot study in adherence to an a priori peer-reviewed protocol. Patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) with an established ERABS protocol between July 2014 and February 2015 were randomly allocated to receive either IPLA with 0.2% ropivacaine (intervention group) or normal saline (control group). We measured pain scores, analgesic consumption and adverse effects. Functional prehabilitation outcomes, including peak expiratory flow (PEF) and the Six Minute Walk Test (6MWT) and Quality of Recovery Survey-40 (QoR-40) scores, were assessed before surgery, and 1 day and 7 days postoperatively. Results: One hundred patients were randomly allocated to the study groups, of whom 92 completed the study, 46 in each group. There were no statistically significant differences between the 2 groups in baseline characteristics or any primary or secondary outcomes. Pain scores and analgesic consumption were low in both groups. There were no adverse events. Significant declines in PEF and 6MWT and QoR-40 scores were noted on postoperative day 1 in both groups; the values returned to baseline on postoperative day 7 in both groups. Conclusion: Intraperitoneal local anesthesia with ropivacaine did not reduce postoperative pain or analgesic consumption when administered intraoperatively to patients undergoing LRYGB. Standardization of the ERABS protocol benefited patients, with functional prehabilitation outcomes returning to baseline postoperatively. Trial regis tration: ClinicalTrials.gov no. NCT 02154763
Integrity of gut mucosa during anaesthesia in major abdominal surgery
Collegium antropologicum, 2011
The aim of the study was to examine a perfusion and integrity of small bowel in 60 subsequent patients during the major open abdominal surgery which lasted from 2 to 7 hours. Two samples of the intestinal mucosa were removed: at the beginning, and at the end of the surgical procedure in general anaesthesia. A mucosal injury was classified into 4 grades. pH, PCO2 and lactate level were measured in the blood samples from the arterial and mesenteric vein in one hour time intervals. The changes of intestinal mucosa were found in 31 patients (51.7%): in 19 patients (31.7%) grade 1 changes were recorded, in 10 patients (16.7%) grade 2, and in 2 patients (3.3%) grade 3. Grade 4 lesions were not recorded. There was a statistically significant correlation between grades of the mucosal damage and the surgery duration (p = 0.001). Analysis during the one hour intervals showed that there was no exact time point when the significant aggravation of the pathohistological changes in intestinal muco...
Enhanced recovery after surgery (ERAS) for the anaesthesiologist
Indian Journal of Clinical Anaesthesia
Enhanced recovery after surgery (ERAS) protocol consists of entire spectrum of pre, intra and postoperative designed to enhance patient outcomes. Since its first introduction for major abdominal surgery in the 1990's, ERAS protocols have been successfully used extensively in many countries in several major surgical procedures. When effectively implemented, ERAS resulted in reduction in hospitalization, improvement in satisfaction of the patients, and reduction in complication rate without an increase in readmissions. Implementation of ERAS in India has also positively affected the patient experience and led to efficient utilization of valuable hospital resources. Many of the ERAS components are linked to the anaesthesia team. Anaesthesiologists help in preparing anaesthesia, they also ascertain the fasting regime in preoperative period, assess premedication, and introduce prophylaxis for post-operative nausea and vomiting (PONV). Intraoperatively, they introduce low sodium fluid therapy, help in preventing hypothermia, and utilize short acting drugs. They also help in important decision making during postoperative analgesia. An anaesthesiologist role is foremost important in the implementation of ERAS protocol. The article aims to discuss the various components of ERAS and the role of anaesthesiologist in implementing them.
Quality of Life and Postoperative Anesthesia in Gastrointestinal Surgery
SpringerReference
The physiological and psychosocial stresses of surgery increase the risk of poor nutritional status, which is clearly linked to poorer outcomes. Poor nutrition therefore has its consequences on quality of life. The evaluation of Quality of Life assesses patients' well-being by taking into account physical, psychological and social conditions. The objectives are to assess the anthropometric parameters, Biochemical parameters, diet history and Quality of Life of the study subjects using Gastrointestinal Quality of Life Index questionnaire (GOQLI) and to compare the nutritional status and Quality of Life scores and to correlate the anthropometric, biochemical parameters and nutrient intake with GIQLI scores. A prospective study using convenient sampling technique was conducted on 50 study subjects to assess their nutritional status and gastrointestinal quality of life. In this study the GIQLI score was divided into overall, physical, emotional and gastrointestinal domains. Observations showed nutritional status had significant association (p<0.05) with physical domain (12.12±14.15). In biochemical parameter albumin had significant association (p<0.05) with emotional domain and nutrient intake was found to have significant association (p<0.01) with emotional domain. In patients admitted for GI surgery the overall and domain specific scores were found to be less when compared with the scores of normal subjects as reported in the previous studies. The overall and domain specific GIQLI scores seem to have association with varying weight loss, serum albumin and nutrient intake. It is understood that gastrointestinal Quality of Life has major impact on the underlying disease progression and recovery, appropriate nutritional intervention and support should be provided at the earliest to prevent further decline in nutritional status and post-operative complications.
Enhanced recovery after surgery: An anesthesiologist's perspective
2019
Enhanced recovery after surgery (ERAS) protocols are a combination of multimodal evidence-based strategies, applied to the conventional perioperative techniques, to reduce postoperative complications and to achieve early recovery. These strategies or protocols, require a dedicated and organized team effort for their implementation to enable early discharge and thus reduce the length of hospital stay. Anesthesiologists play an important role in facilitating these protocols as some of the key elements such as preoperative patient preparation and assessment, perioperative fluid management, and perioperative pain relief are handled by them. This article discusses in detail the various components of ERAS and the anesthesiologist's role in implementing them.