Enhanced recovery after surgery (ERAS) Traditional care on POD#1 ERAS care on POD#1 Enhanced recovery in gynecologic surgery improving post-operative care Jocelyn S. Chapman, MD Assistant Professor Department of Obstetrics, Gynecology & Reproductive Sciences Division of Gynecologic Oncology University of California San Francisco 2017 UCSF Obstetrics and Gynecology Update: What Does the Evidence Tell Us? Objectives Principles of ERAS – multiple small interventions effect big changes. What is the rationale for the ERAS pathway? What are the key elements of an ERAS pathway? What patients are likely to benefit from an ERAS pathway? 1
Principles of ERAS – an ounce of One way to reduce length of stay… prevention… Prevention Cure ERAS pathways for gynecologic Standing on the shoulders of giants – surgery: who and how? ERAS improves post-op outcomes Marx et al. Chase et al. Gerardi et al. Carter et al. Kalogera et Wijk et al. Outcomes (2006) (2008) (2008) (2012) al. (2013) (2014) Abdominal or Cytoreductive Cytoreductive Type of Cytoreductive vaginal Cytoreductive surgery, open Abdominal surgery & open surgery surgery hysterectomy; surgery staging & pelvic hysterectomy staging open staging organ prolapse Length of stay -1 day NS -3 days NS -3 days -0.5 days difference Postoperative NS NS NS NS NS NS complications Mortality NS NS NS NS NS NS NS NS NS NS NS NS Readmissions NS -- NS NS -- NS Reoperations Total hospital -- -- 6293 -- 6634 -- cost difference Pitter MC, Simmonds C, Seshadri-Kreaden U, Hubert HB. The Impact of Different Surgical Modalities for Hysterectomy on Satisfaction and Patient Reported Outcomes. Interact J Med Res 2014;3(3):e11. Table adapted from Nelson, Kalogara & Dowdy in Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol. 2014 Dec;135(3):586-94. 2
Our motivation: discharge by noon ERAS implementation: like herding cats At least I’m not responsible for implementing ERAS… Why would trainees undertake such Patient education a task? PREPARING FOR ENHANCED RECOVERY Expecta ons for prior to surgery Surgeons, Anesthesia • On the day before surgery you may eat what you like. • A er midnight on the day of surgery, you may con nue to drink water, Boost Breeze (available for free on the 3 rd floor of Mt. Zion), Gatorade, Faculty, OR Staff & or filtered, clear apple juice. • You must stop drinking 2 hours prior to surgery. If you con nue to drink or drink fluids other than those listed above, then the anesthesia Nursing personnel doctors will cancel your surgery for safety reasons. Expecta ons for the evening of surgery • Your nurse will be helping you get out of bed 6 hours a er surgery. • Your bladder catheter will be removed 6 hours a er surgery, and you will be able to urinate on your own. • It is our top priority that you are as comfortable as possible, and you will have access to as many oral pain medica ons as needed to control your discomfort. Expecta ons for the morning a er surgery • You will be able to eat a regular diet on the day following your surgery. • You will be able to return home the day following your surgery. ERAS • You will be asked to fill out a pa ent sa sfac on survey prior to discharge from the hospital. Expecta ons for home • You will be sore a er surgery and may need to take pain medica ons. • You should consider having a family member or friend assist you at home as you recover. Residents & Fellows • You will be able to reach your doctors by phone if you have concerns during recovery. Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466. 3
Cohort Characteristics ERAS protocol for minimally invasive GynOnc surgery ERAS Controls Pre-op P-value (n=55) (n=110) Boost Breeze Age, years 59.3 (20.1-83.1) 59.3 (15.4-88.6) 0.989 No bowel ASA status 2 (1-4) 2 (1-4) 0.569 prep Length of Surgery, minutes 214 (16-376) 199 (58-470) 0.802 Gabapentin, APAP, Intra-op Estimated Blood Loss (EBL), mL 100 (10-1000) 150 (5-3000) 0.800 NSAID Multi-modal anti-emetics Robotic cases 26 (47) 55 (50) 0.741 Post-operative Diagnosis 0.280 TAP block or IV lidocaine 32 (58) 68 (53) Uterine cancer Post-op Minimize Walk and Ovarian Cancer 10 (18) 19 (44) fluids foley out within 6 hrs 7 (13) 20 (3) Cervical cancer / dysplasia Gabapentin, APAP, Other cancer 1 (2) 1 NSAID Benign 5 (9) 2 Regular Diet Data are n (%), mean±standard deviation, or median (interquartile range). Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466. Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466. Compliance with ERAS elements Compliance with ERAS elements Multi-modal pain interventions pre- & post-operatively Anti-emetics, diet, fluids & urinary catheter ERAS Controls ERAS Controls P-value P-value (n=55) (n=110) (n=55) (n=110) Post-operative nausea & vomiting TAP block 32 (58) 0 < 0.0001 0.009 intra-operative prophylaxis Multimodal Gabapentin 44 (80) 2 (2) < 0.0001 43 (78) 59 (53) operative anti-emetics Pre- Tylenol 45 (82) 2 (2) < 0.0001 11 (20) 48 (44) Single NSAIDs 25 (46) 0 < 0.0001 1 (2) 3 (3) None Gabapentin < 0.0001 33 (60) 6 (5) operative 51 (93) 69 (62) < 0.0001 Regular / Diabetic Diet Post- Tylenol 51 (93) 88 (80) 0.034 1500 (200-3400) 1400 (200-7200) 0.60 Intra-operative fluids, mL NSAIDs 0.481 12 (22) 19 (17) Urinary catheter duration + , hours 11 (2-18) 21 (1-80) < 0.0001 + patients who underwent radical hysterectomy had urinary catheter management per primary surgeon’s discretion Data are n (%), mean±standard deviation, or median (interquartile range). Data are n (%), mean±standard deviation, or median (interquartile range). Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466. Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466. 4
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