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Published on January 09, 2018

Surgery Program Improves Perioperative Care and Recovery

Impact of Enhanced Recovery After Surgery

In 2014, researchers using an ERAS protocol followed patients undergoing elective colorectal surgery at the University of Virginia Medical Center. The study involved 109 patients in the ERAS group and 98 in the conventional group.

With the ERAS group, investigators found:

  • Length of stay – Decreased 2.2 days
  • Overall complication rate – Decreased 17%
  • Satisfaction with pain control – Increased 55%

In addition, the ERAS approach reduced healthcare costs $7,129 per patient, with a cost savings of more than $777,061.

Source: Journal of the American College of Surgeons, April 2015

North Kansas City Hospital has implemented an evidence-based perioperative care strategy called enhanced recovery after surgery. The goal of ERAS is to bring patients to normal function earlier than current standards by minimizing the use of narcotics for pain management, optimizing preoperative and postoperative nutrition, and promoting early mobility after surgery.

“ERAS leads to reduced surgical complications and infections, fewer readmissions, better patient comfort, shorter hospital stays and improved outcomes,” explained Mangesh D. Oza, MD, FACS, a general surgeon with Meritas Health Comprehensive Surgery.

North Kansas City Hospital’s ERAS program will begin in mid-February with colorectal surgery patients. Other specialties, including orthopedics and gynecology, will institute ERAS in the coming months.

Education and Collaboration

Key to the success of the hospital’s ERAS program is education and collaboration. “Getting patients on board is the biggest hurdle,” Dr. Oza said. “Referring physicians should be aware that patients will be required to follow some fairly strict protocols to help them get through the perioperative period. This also is a multidisciplinary approach with hospitalists and staff from the presurgery clinic, pharmacy, preop, anesthesia, surgery, the PACU, nursing units, nutrition services and rehabilitation. Combining these efforts also helps improve patient satisfaction.”

Dr. Oza and other surgeons at NKCH adhere to ERAS clinical practice guidelines, such as those published by the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. These guidelines note that transversus abdominis plane blocks with a local anesthetic have been associated with decreased length of stay compared with systemic opioids in laparoscopic colorectal surgery, and that TAP blocks performed before surgery appear to provide better analgesia than TAP blocks performed at the end.

“Using TAP blocks and local anesthetic, IV acetaminophen, gabapentin and nonsteroidal anti-inflammatory drugs reduces patient narcotic requirements,” Dr. Oza noted. “The side effects of narcotics – forming an ileus – can be obviated by either not using or reducing narcotics. Some patients may not require postoperative narcotics. In addition to maintaining intestinal integrity, better pain control means patients ambulate faster, which reduces the risk of forming a blood DVT or pulmonary embolism, and they avoid going home on an opioid.”

Advantages for At-risk Patients

The ERAS approach to pain management provides advantages in the timing of when patients consume food and drink liquids, which are:

  • Six hours before surgery: Eat solids and drink liquids.
  • Three hours before surgery: Drink clear electrolytes.
  • Immediately after surgery: Eat food and drink liquids.

Because patients with Type 1 diabetes can consume carbohydrates closer to their surgery, their bodies can compensate for the effects of colorectal surgery bowel prep on their insulin levels. Dr. Oza added that such care is coordinated with the patient’s endocrinologist.

Family members also face challenges keeping a loved one with dementia on NPO. They may not understand the restrictions. “The shortened NPO window with ERAS reduces those challenges,” Dr. Oza said.

Mangesh D. Oza, MD, FACS

Mangesh D. Oza, MD, FACSDr. Oza earned his medical degree from the University of Missouri-Kansas City. He completed his surgery residency at the Alton Ochsner Medical Foundation Hospital.