By: 23 June 2014
Enhanced recovery for surgery patients gains favour in the US

Changes in managing patients before, during and after colorectal surgery could cut hospital stays by two days and reduced readmission rates, according to researchers at Duke University Hospital in North Carolina.

Enhanced recovery after surgery (ERAS) has already gained favour in Europe but has not been widely used in the United States. The practice aims to standardise perioperative care using procedures backed by scientific evidence that demonstrate their benefits. It is easier on patients before surgery, doing away with the fasting period and bowel evacuation that are typically prescribed. After surgery, patients are encouraged to eat and move about as soon as possible, leading to faster recoveries.

Among findings published in the May 2014 issue of the journal Anesthesia & Analgesia, the researchers reported that the enhanced recovery approach used for colorectal surgery cut hospital admissions from an average of seven days to five, and reduced the rate of readmissions by half.

“Enhanced recovery is about change management,” said author Tong Gan, professor of anaesthesiology at Duke. “It’s getting the team together, including nurses, anaesthesiologists, surgeons and patients, with everyone understanding the expectations of how to do things differently and improve patient care.”

Gan and colleagues collected data from 241 consecutive patients who were undergoing colorectal surgery at Duke University Hospital before and after the enhanced recovery
approach was implemented. Ninety-nine patients were studied in the traditional approach, and 142 using enhanced recovery.

With traditional perioperative care, few procedures are standardised; however, patients are typically told to fast the night before and undergo laxative treatments, and are not given food or drink after surgery until bowel sounds are restored, sometimes several days later. A variety of different anaesthesia regimens, fluid management and pain control are used, according to the surgical team’s preferences. Furthermore, patients who experience pain, stress, immobilization, and postoperative constipation can remain in hospital for 10 days or more.

In the Duke study, patients in the enhanced recovery group were educated about what they should expect. Routine bowel preparation was not performed, and patients were allowed to drink clear fluids until three hours before their surgeries, notably a sports drink.

All of the ERAS patients received an epidural as well as non-opioid painkillers to reduce opioid side-effects such as nausea, vomiting, constipation, urinary retention and drowsiness. They then underwent general anaesthesia. After surgery, the patients transitioned to oral acetaminophen or other non-steroidal anti-inflammatory drugs, plus oral opioids, if necessary, after about 72 hours. Patients were also encouraged to drink liquids and get out of bed on the day of surgery, and for at least six hours every
subsequent day.

“We are increasing the quality of care for patients while at the same time reducing complications and medical costs,” said Timothy Miller, assistant professor of anesthesiology at Duke. “I believe that going forward, enhanced recovery care could become the new standard for best practice.”