AWR ERAS

Table of Contents

No.	Key Element	Page #
1.	Pre-operative Risk Stratification	3
2.	Pre-operative Counseling	4
3.	Pre-operative Bowel Preparation	4
4.	Prophylaxis against Thromboembolism	4
5.	Methicillin Resistant Staphylococcus Aureus (MRSA) Prophylaxis	5
6.	Nutritional Preparation	5
7.	Pre-operative Fasting and Carbohydrate Treatment	5
8.	Peri-operative Fluid Management	6
9.	Post-operative Nausea and Vomiting	6
10.	Nasogastric Intubation	7
11.	Urinary Drainage	7
12.	Prevention of Intraoperative Hypothermia	7
13.	Multimodal Pain Management	8
14.	Acceleration of Intestinal Recovery	8
15.	Early Mobilization	9
16.	Post-operative Glucose Control	9
17.	Auditing of ERAS	10
	Summary of Pre-operative Recommendations	11-13
	Summary of Intra-operative Recommendations	14
	Summary of Post-operative Recommendations	15-16
	References	17-18

1. Pre-operative Risk Stratification

a.         Smoking and Alcohol Cessation

Smoking and alcohol use are both patients factors that have been shown to have a negative impact on post-operative outcomes. Current smokers have an increased risk of pulmonary and wound complications. An increased risk of complications of bleeding, wound and cardiopulmonary complications has been associated with alcohol abuse. A month of abstinence from both products is needed to reduce the risk of complications.^1,2

Specific Recommendations:

1.                       Smoking cessation for no less than 4 weeks pre-operatively.

2.                       Alcohol use cessation for 4 weeks pre-operatively.

b.         Diabetes Control and Management

HbA1c ≥6.5% has been found to be more strongly associated with major postoperative complications than perioperative hyperglycemia or diabetes status, and to be associated with perioperative hyperglycemia. In addition, one third of previously undiagnosed diabetics undergoing preoperative testing had elevated HbA1c levels. Given these findings, more liberal testing of HbA1c levels should be considered in diabetic and high-risk nondiabetic patients undergoing elective surgery.³

Specific Recommendations

1.   HbA1c to be ≤ 8 % prior to surgery scheduling.

c.         Weight Optimization

Body mass index (BMI) is considered a significant predictor for surgical site occurrence when analyzed as a continuous variable, suggesting that risk increases with increasing BMI and optimization of comorbidities prior to surgical intervention is recommended.⁴

Specific Recommendations:

1.   Body mass index ≤ 40kg/m² or as otherwise specified prior to surgery scheduling.

2. Pre-operative Counseling

Patient verbal and written education to include principles of nutrition optimization, MRSA prophylaxis, early mobilization, expectations for post-operative pain control in order to decrease patient anxiety and may improve recovery. Instruction concerning the specifics of the ERAS protocol to be included in pre-operative teaching.⁵

Specific Recommendations:

1.     Surgeon and nurse to routinely provide pre-operative counseling to patient and family member.

2.     Verbal, written and multimedia information to explain the procedure and specific tasks that patient will need to accomplish related to ERAS protocol.

3. Pre-operative Bowel Preparation

Because mechanical bowel preparation has adverse physiologic effects attributed to dehydration, patient distress, and is associated with prolonged ileus post-operatively, it should not be used routinely.⁶

Specific Recommendations:

1. Mechanical bowel preparation is not recommended for patients preparing to undergo hernia repair with abdominal wall reconstruction.
2. Patients with colostomy need to take clear liquid only diet for two days pre-operatively (in addition to the Impact AR).

4. Prophylaxis against Thromboembolism

Patients with malignant disease, previous pelvic surgery, taking corticosteroids pre-operatively, extensive comorbidity and hypercoagulable states are at increased risk of deep vein thrombosis (DVT). The incidence of DVT is approximately 30% for patients having colorectal surgery who do not undergo thromboprophylaxis, and fatal pulmonary embolus (PE) occurs in approximately 1% of patients. Multimodal prophylaxis includes: well-fitted compression stockings, intermittent pneumatic compression, and pharmacologics with heparin or low-molecular-weight heparin. Extended prophylaxis for 28 days should be given to patients with colorectal cancer.⁷

Specific Recommendations: Prophylactic Treatment

1.     Sequential Compression System (SCD) intra- and post-operatively.

2.     Pharmacological prophylaxis with heparin or low-molecular-weight heparin preoperatively and continued until the time of discharge.

5. Methicillin Resistant Staphylococcus Aureus (MRSA) Prophylaxis

Mupirocin intranasal ointment bid and chlorhexidine showers x 5 days combined are considered effective decolonization procedures.⁸

Specific Recommendations: Prophylactic Treatment for all patients:

1.     Chlorhexidine (Hibiclens) shower once daily x 5 days and morning of surgery.

2.     Povidone Iodine Solution: Apply to each nares per protocol at least 1 hour, but not more than 2 hours prior to surgery unless allergic to iodine or shellfish. (transitioned to this rather than mupirocin intranasal ointment January, 2017).

6. Nutritional Preparation

An oral immune-enhancing nutritional supplement taken for five days pre-operatively has been shown to result in increased pre-operative serum arginine concentration and decreased number of post-operative infections and better preserved renal function.⁹

Specific Recommendations:

1.              All patients to receive Impact AR to be taken po TID x 5 days pre-operatively

7. Pre-operative Fasting and Carbohydrate Treatment

No scientific evidence exists that provides basis for fasting from midnight pre-operatively. By providing a clear fluid that contains a relatively high concentration of complex carbohydrates 2-3 hours before induction of anesthesia, patients can undergo surgery in a metabolically fed state. 400mL of a 12.5% drink of mainly maltodextrins reduces pre-operative thirst, hunger and anxiety and post-operative insulin resistance, results in less post-operative losses of nitrogen and protein and better-maintained lean body mass and muscle strength.^10-12

Specific Recommendations:

1.     Patients to take clear fluids up to 4 hours before arrival time for surgery and solids for up to 8 hours prior to induction of anesthesia.

2.     Pre-operative oral carbohydrate loading with Gatorade 400mL to be taken by patients 4 hours before arrival time for surgery.

3.     In diabetic patients, preoperative oral carbohydrate loading is performed with G2 (Gatorade Low Calorie Hydration) and is to be taken at midnight. After midnight, diabetic patients to be NPO.

8. Peri-operative Fluid Management

Fluid therapy plays an important role in patient outcomes after surgery. Balanced crystalloids are preferred to 0.9% saline. In open surgery, patients should receive intraoperative fluids (colloids and crystalloids) guided by flow measurements to optimize cardiac output. Flow measurement should be considered if: patient is at high risk with comorbidities, if blood loss is >7 mg/kg, or in prolonged procedures. Vasopressors should be considered for intra- and post-operative management of epidural-induced hypotension provided the patient is normovolemic. Enteral route for fluid post-operatively should be used as early as possible, and IVFs should be discontinued as soon as is practicable. A standard anesthetic protocol allowing rapid awakening should be given. The anesthetist should control fluid therapy, analgesia and hemodynamic changes to reduce the metabolic stress response.^13,14

Specific Recommendations:

1.     In the normovolemic patient, blood pressure should be maintained using vasopressors to avoid fluid overload.

2.     Fluid shifts should be minimized if possible: avoid bowel preparation, maintain hydration by giving oral preload up to 4 hours before surgery, minimize bowel handling and exteriorization of the bowel outside the abdominal cavity and avoiding blood loss.

3.     Post-operative intravenous fluids should be minimized to maintain normovolemia and avoid fluid excess.

4.     Hypotensive normovolemic patients with thoracic epidural anesthesia should be treated with vasopressors and not an excess of fluid.

5.     Discontinue intravenous fluids at earliest opportunity.

6.     Enteral route for fluids post-operatively should be used as early as possible.

7.     Balanced crystalloids preferred to 0.9% saline.

9. Post-operative Nausea and Vomiting

Post-operative nausea and vomiting affects 25-35% of all surgical patients and is a leading cause of patient dissatisfaction and delayed discharge from the hospital. A multimodal approach to prophylaxis should be adopted in all patients with ≥ 2 risk factors undergoing major colorectal surgery. Treatment also should utilize a multimodal approach. Non-pharmacological techniques include the avoidance of emetogenic stimuli such as inhalational anesthetics and the increased use of propofol for the induction and maintenance of anesthesia. Minimal preoperative fasting, carbohydrate loading and adequate hydration of patients can also have a beneficial effect.^15,16

Specific Recommendations: A multimodal approach for prevention in patients with two or more risk factors. In the presence of post-operative nausea/vomiting, a multimodal treatment approach should be taken.

10. Nasogastric Intubation

Routine nasogastric decompression should be avoided after colorectal surgery because fever, atelectasis, and pneumonia are reduced in patients without a nasogastric tube. Multiple RCTs have shown a reduction of the time interval from surgery to first passage of flatus by half a day if nasogastric intubation was avoided.¹⁷

Specific Recommendations: Post-operative nasogastric tubes should not be used routinely. Nasogastric tubes inserted during surgery should be removed before reversal of anesthesia.

11. Urinary Drainage

A brief duration of transurethral drainage is desirable because increasing duration is associated with increasing risk of urinary tract infection. Early removal is associated with significantly reduced prevalence of urinary tract infection. The bladder catheter can be removed regardless of the usage or duration of thoracic epidural analgesia (TEA).¹⁸

            Specific Recommendations: Routine bladder drainage for 1-2 days. Remove bladder catheter per hospital protocol. Catheter can be removed regardless of use or duration of thoracic epidural analgesia.

12. Prevention of Intraoperative Hypothermia

Patients becoming hypothermic (< 36° C) have been shown to have higher rates of wound infection, and morbid cardiac events and bleeding. Maintenance of patient’s temperature, rather than restoration after it drops, is important and can be accomplished with a suitable warming device and warmed intravenous fluids should be used routinely to keep body temperature > 36° C. Monitoring is essential to titrate warming devices and to avoid hyperpyrexia.¹⁹

Specific Recommendations: Warming device such as forced-air heating blankets and warmed intravenous fluids should be routinely used to keep body temperature > 36° C. Monitor temperature to avoid hyperpyrexia.

13. Multimodal Pain Management

Optimized pain management can be achieved utilizing multimodal pain control in the early and late post-operative periods, with intention of minimizing the use of opiates. Return of bowel function allows patients to tolerate longer-acting enteral pain medications; therefore, accelerating the return of intestinal recovery is intimately related to pain control. Intraoperative transversus abdominis plane (TAP) block with Exparel (20mL diluted to 120 mL) (which however is not offered at our institution so cannot utilize), multimodal pain control, acceleration of intestinal recovery to hasten use of enteral pain medications, minimize use of opiates.²⁰

Specific Recommendations:

Multimodal therapy with intention of minimizing the use of opiates.

1.     Chandler:  Epidural (Dilaudid and Bupivacaine)

GSH:  Epidural (Bupivacaine): IV PCA: (Dilaudid)

2.     Acetaminophen 1 gm IV q 6 h x 24h (48h if not tolerate PO)

2a. Transition to Acetaminophen 650mg PO Q6h scheduled at 24 hours postoperatively

3.   Gabapentin 300 mg PO TID starting on night of surgery

4.   Toradol 15mg IV q6h, starting on night of surgery (Hold for any renal dysfunction)

4a. Transition to ibuprofen 600 mg po q6h at 48 hours (if no ileus or renal dysfunction)

5.   Cyclobenzaprine 5mg PO TID starting on night of surgery

5a. Diazepam 5 mg IV Q6h prn for break through spasms

5b. Hold Diazepam for OSA or sedation

5c. Limit Diazepam to 2.5mg for patients over 65 years old

6.   Oxycodone 5-10 mg po q 4 h prn after IV PCA or epidural discontinued

7.   Lidoderm starting on POD3 or when the epidural is being discontinued

14. Acceleration of Intestinal Recovery

Hastened recovery of intestinal function is intricately tied to multimodal pain management, both of which are associated with diminishing stress response of the trauma of surgery. The concept of multimodal pain management requires early return of bowel function in order that patients are able to tolerate longer-acting enteral pain medications. Early return of bowel function would be achieved by allowing early feeding, judicious intravenous fluid administration, and use of alvimopan.²⁰

Specific Recommendations:

1.     Docusate-senna 50mg-8.6mg PO BID

2.     Alvimopan (Entereg) 12mg po to be administered 30-90 minutes pre-operatively

**Do not give Entereg if patient has not been opioid-free x 7 days preoperatively.**

3.     Alvimopan (Entereg) 12mg po to be administered BID post-operatively until patient has a bowel movement or POD 7.

4.     Multimodal pain control intended to minimize the use of opiates.

5.     Diet Advancement Protocol:

POD 0: Ice chips, sips of water

POD 1: Clear liquids at rate of ≤ 250 cc/8 hours

POD 2: Unlimited clear liquids

POD 3: Regular diet

15. Early Mobilization

Patient mobilization early in the post-operative period is thought to reduce chest complications and may counteract insulin resistance brought on with immobilization. Mobilization on POD 1-3 is a factor significantly associated with a successful outcome of ERAS, and failure to mobilize on POD 1 maybe due to inadequate control of pain, continued IVFs, indwelling urinary catheter, patient motivation, and pre-existing co-morbidities. Failure to mobilize is one of the most common reasons for ERAS deviation and is associated with prolonged LOS.²¹

Specific Recommendations:

1.     Patients to be assisted out of bed to chair on evening of surgery.

2.     Patients to be assisted to ambulate TID starting on POD 1.

3.     Physical Therapy consult if needed in order to facilitate early and regular ambulation.

16. Post-operative Glucose Control

Increasing insulin resistance and glucose levels have been shown to be associated with complications and mortality after major abdominal surgery. The risk increases with higher insulin resistance and/or higher glucose levels. Several ERAS elements affect insulin action/resistance, thereby improving glycemic control with no risk of causing hypoglycemia.²²

Specific Recommendations: Insulin should be used judiciously to maintain blood glucose as low as feasible with the available resources.

17. Auditing of ERAS 

In order to continue to improve practice, it will be necessary to measure clinical outcomes of ERAS such as LOS, readmission rate and complications. Process evaluation (measuring compliance) will be an important component to assist providers in implementing the ERAS protocol and in understanding its successes and failures.²³

Specific Recommendations:

1.     Audit of compliance (process evaluation)

2.     Audit of LOS, readmissions, complications (outcome evaluation)

Summary of Pre-operative Recommendations

ERAS Element	Recommendations	Rationale	Evidence
Risk Stratification	a. Smoking and alcohol cessation Smoking cessation and alcohol cessation x 4 weeks pre-operatively minimum b. Diabetes control and management HbA1c to be ≤ 8 % prior to surgery scheduling. c. Weight optimization Body mass index ≤ 40kg/m2 prior to surgery scheduling.	a. To decrease risk of pulmonary and wound complications (smoking cessation). To decrease risk of bleeding, wound and cardiopulmonary complications (alcohol cessation). b. HbA1c ≥6.5% has been found to be more strongly associated with major postoperative complications than perioperative hyperglycemia or diabetes status, and to be associated with perioperative hyperglycemia. In addition, one third of previously undiagnosed diabetics undergoing preoperative testing had elevated HbA1c levels. Given these findings, more liberal testing of HbA1c levels should be considered in diabetic and high-risk nondiabetic patients undergoing elective surgery. c. Body mass index (BMI) is considered a significant predictor for surgical site occurrence when analyzed as a continuous variable, suggesting that risk increases with increasing BMI and optimization of comorbidities prior to surgical intervention is recommended.	T⊘nnesen H, Rosenberg J, Nielsen H J, Rasmussen V, Hauge C, Pedersen IK, Kehlet H. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. British Medical Journal 1999, 318, 1311-1316. Sorensen L; Karlsmark T; Gottrup, Finn M. Abstinence from smoking reduces incisional wound infection: A randomized controlled trial, Annals of Surgery 2003, 238(1). Liang MK, Nguyen MT, Nguyen DH, Holihan JL, Awawadi ZM, Roth JS, Wray CJ, Ko TC, Kao LS. Preoperative glycosylated hemoglobin and postoperative glucose together predict major complications after abdominal surgery, Journal of the American College of Surgeons 2015, 221(4), 854-861. Berger RL, Li LT, Hicks SC, Davila JA, Kao LS, Liang MK. (). Development and validation of a risk-stratification score for surgical site occurrence and surgical site infection after open ventral hernia repair. Journal of the American College of Surgeons 2013, 217(6), 974-982. doi: http://dx.doi.org/10.1016/j.jamcollsurg.2013.08.003
Counseling	Pre-operative review of post-operative expectations, principles of optimization protocols, expectations for pain control to be done at pre-operative office visit by surgeon and nurse	To diminish fear and anxiety and enhance post-operative recovery and quick hospital discharge	Kiecolt-Glaser, Janice K; Page, Gayle G.; Marucha, PT.; MacCallum, RC; Glaser, R.  Psychological Influences on Surgical Recovery: Perspectives American Psychologist 1998, 53(11), 1209–1218.
ERAS Element	Recommendations	Rationale	Evidence
Prophylaxis against Thromboembolism	Prophylactic treatment to include SCDs intra- and post-operatively, pharmacological prophylaxis with subcutaneous heparin or LMWH pre-operatively and post-operatively.	To prevent deep vein thrombosis and pulmonary embolus.	Kwon S, Meissner M, Symons R, Steele S, Thirlby R, Billinghma R, Flum DR. Perioperative pharmacologic prophylaxis for venous thromboembolism in colorectal surgery. Journal of the American College of Surgeons 2011, 213 (5), 596–603.
Fasting and Carbohydrate Treatment	Clear liquids up to 2 hours and solids up to 8 hours prior to induction of anesthesia. Pre-operative oral carbohydrate loading with Gatorade 400mL to be taken by patients 4 hours before arrival time for surgery. In diabetic patients, preoperative oral carbohydrate loading is performed with G2 (Gatorade Low Calorie Hydration).	Surgery can be performed with patient in a metabolically-fed state	Brady M, Kinn S, Stuart P, Ness V. Preoperative fasting for adults to prevent perioperative complications, Cochrane Database of Systematic Reviews 2003, 4.. Noblett S E, Watson D S, Huong H, Davison B, Hainsworth P, Horgan AF. Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Disease 2006, 8(7), 563-569. Hausel J; Nygren J; Lagerkranser M; Hellström, Per M; Hammarqvist F; Almström C; Lindh A; Thorell A; Ljungqvist O. A Carbohydrate-Rich Drink Reduces Preoperative Discomfort in Elective Surgery Patients. Anesthesia & Analgesia 2001, 93(5), 1344–1350.
Nutritional Preparation	Impact AR TID x 5 days	To increase pre-operative serum arginine concentration and decrease number of post-operative infections and preserve renal function.	Tepaske R, Velthuis H, Oudemans-van Straaten HM, Heisterkamp SH, van Deventer SJ, Ince C, Eysman L, Kesecioglu J. Effect of preoperative oral immune-enhancing nutritional supplement on patients at high risk of infection after cardiac surgery: a randomised placebo-controlled trial. Lancet 2001 358 (9283) 696-701.
MRSA prophylaxis	Mupirocin 2% intranasal ointment bid x 5 d , Hibiclens shower x 5 d and morning of surgery. Povidone Iodine Solution: Apply to each nares per protocol at least 1 hour, but not more than 2 hours prior to surgery unless allergic to iodine or shellfish. (will transition to this rather than mupirocin ointment 2017).	MRSA decolonization.	Buehlmann, B. M. M. D., Frei, R. M., Fenner, L. M., Dangel, M. M., Fluckiger, U. M., & Widmer, A. F. M. M. Highly Effective Regimen for Decolonization of Methicillin-Resistant Staphylococcus aureus Carriers. Infection Control and Hospital Epidemiology 2008, 29(6), 510-516.
ERAS Element	Recommendations	Rationale	Evidence
Acceleration of Intestinal Recovery	Clear liquids until four hours pre-operatively; Entereg 12mg PO in pre-op holding area**Do not give Entereg if patient has not been opioid-free x 7 days preoperatively.**	To aid in diminishing stress response of the trauma of surgery.	Fayezizadeh M, Petro CC, Rosen MJ, Novitsky YW. Enhanced recovery after surgery pathway for abdominal wall reconstruction: Pilot study and preliminary outcomes. Plastic and Reconstructive Surgery 2014, 134(4S-2), 151S-159S.
Bowel Preparation	Patients with colostomy to take clear liquid only diet for two days pre-operatively.	Mechanical bowel prep has adverse effects attributed to dehydration, patient distress and is associated with prolonged ileus post-operatively.	Güenaga KF, Matos D, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery, Cochrane Database of Systematic Reviews 2011.
Post-operative Nausea/Vomiting	Multimodal approach for prevention for patients with ≥ 2 risk factors.	To increase patient satisfaction and promote earlier hospital discharge.	Carlisle J, Stevenson CA. Drugs for preventing postoperative nausea and vomiting. Cochrane Database of Systematic Reviews 2006 (3). Apfel CC, Kranke P, Eberhart L H J, Roos A, Roewer N. Comparison of predictive models for postoperative nausea and vomiting. British Journal of Anaesthesia 2002, 88(2), 234-240.

Summary of Intra-operative Recommendations

ERAS Element	Recommendations	Rationale	Evidence
Fluid Management	In the normovolemic patient, blood pressure should be maintained using vasopressors to avoid fluid overload. Fluid shifts should be minimized if possible: avoid bowel preparation, maintain hydration by giving oral preload up to 4 hours before surgery, minimize bowel handling and exteriorization of the bowel outside the abdominal cavity and avoiding blood loss. Hypotensive normovolemic patients with thoracic epidural anesthesia should be treated with vasopressors and not an excess of fluid. Balanced crystalloids preferred to 0.9% saline.	To reduce metabolic stress response and fluid overload.	Varadhan KK., Lobo DN. A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proceedings of the Nutrition Society 2010, 69(04), 488-498. Levy BF, Fawcett W.J, Scott, M J P, Rockall, TA. Intra-operative oxygen delivery in infusion volume-optimized patients undergoing laparoscopic colorectal surgery within an enhanced recovery programme: The effect of different analgesic modalities. Colorectal Disease 2012, 14(7), 887-892.
Multimodal Pain Management	IV or epidural Dilaudid PCA with IV Tylenol and conversion to PO narcotic and non-narcotic adjuncts.	To minimize use of opiates.	Fayezizadeh M, Petro CC, Rosen MJ, Novitsky YW. Enhanced recovery after surgery pathway for abdominal wall reconstruction: Pilot study and preliminary outcomes. Plastic and Reconstructive Surgery 2014, 134(4S-2), 151S-159S.
Nasogastric Intubation	Remove NG tube inserted during surgery before reversal of anesthesia.	To hasten return of bowel function and decrease incidence of fever, atelectasis and pneumonia.	Rao W, Zhang X, Zhang J, Yan R, Hu Z, Wang Q. The role of nasogastric tube in decompression after elective colon and rectum surgery: a meta-analysis. International Journal of Colorectal Disease 2011, 26(4), 423-429.
Urinary Drainage	Routine bladder drainage for 1-2 days. Remove catheter on POD 1 regardless of use or duration of thoracic epidural analgesia.	To decrease risk of urinary tract infection.	Zaouter C, Kaneva P, Carli F. Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia. Regional Anesthesia and Pain Medicine 2009, 34(6), 542-548.
Prevention of hypothermia	Warming device such as forced-air heating blankets and warmed IVFs to keep body temperature >36°C. Monitor temp. to avoid hyperpyrexia.	To decrease rates of wound infection, morbid cardiac events and bleeding.	Kurz, A., Sessler, D. I., & Lenhardt, R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. New England Journal of Medicine 1996, 334(19), 1209-1216.

Summary of Post-operative Recommendations

ERAS Element	Recommendations	Rationale	Evidence
Multimodal Pain Management	IV or epidural Dilaudid PCA with IV Tylenol and conversion to PO narcotic and non-narcotic adjuncts.	To minimize use of opiates.	Fayezizadeh M, Petro CC, Rosen MJ, Novitsky YW. Enhanced recovery after surgery pathway for abdominal wall reconstruction: Pilot study and preliminary outcomes. Plastic and Reconstructive Surgery 2014, 134(4S-2), 151S-159S.
Fluid Management	Post-operative IVFs should be minimized to maintain normovolemia and avoid fluid excess.	To reduce metabolic stress response.	Varadhan KK., Lobo DN. A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proceedings of the Nutrition Society 2010, 69(04), 488-498. Levy BF, Fawcett W.J, Scott, M J P, Rockall, TA. Intra-operative oxygen delivery in infusion volume-optimized patients undergoing laparoscopic colorectal surgery within an enhanced recovery programme: The effect of different analgesic modalities. Colorectal Disease 2012, 14(7), 887-892.
Early mobilization	Out of bed to chair evening of surgery, ambulate TID starting on POD 1	To reduce chest complications and counteract insulin resistance brought on with immobilization.	Convertino V. Cardiovascular consequences of bed rest: effect on maximal oxygen uptake. Medicine & Science in Sports & Exercise 1997, 29(2), 191-196.
Acceleration of intestinal recovery	Entereg 12mg PO q12h until discharge or POD 7 **Do not give Entereg if patient has not been opioid-free x 7 days preoperatively.**	Early feeding to include limited clear liquids on POD 0, Clear liquids on POD 102, regular diet POD 3	Fayezizadeh M, Petro CC, Rosen MJ, Novitsky YW. Enhanced recovery after surgery pathway for abdominal wall reconstruction: Pilot study and preliminary outcomes. Plastic and Reconstructive Surgery 2014, 134(4S-2), 151S-159S.
Post-operative Nausea/Vomiting	Multimodal treatment approach should be taken in the presence of post-operative nausea/vomiting.	To increase patient satisfaction and promote earlier hospital discharge.	Carlisle J, Stevenson CA. Drugs for preventing postoperative nausea and vomiting. Cochrane Database of Systematic Reviews 2006 (3). Apfel CC, Kranke P, Eberhart L H J, Roos A, Roewer N. Comparison of predictive models for postoperative nausea and vomiting. British Journal of Anaesthesia 2002, 88(2), 234-240.
Post-operative Summary, cont.   ERAS Element	Recommendations	Rationale	Evidence
Prophylaxis against Thromboembolism	Prophylactic treatment to include SCDs intra- and post-operatively, pharmacological prophylaxis with subcutaneous heparin pre-operatively.	To prevent deep vein thrombosis and pulmonary embolus.	Kwon S, Meissner M, Symons R, Steele S, Thirlby R, Billinghma R, Flum DR. Perioperative pharmacologic prophylaxis for venous thromboembolism in colorectal surgery. Journal of the American College of Surgeons 2011, 213 (5), 596–603.
Urinary Drainage	Routine bladder drainage for 1-2 days. Remove catheter on POD 1 regardless of use or duration of thoracic epidural analgesia.	To decrease risk of urinary tract infection.	Zaouter C, Kaneva P, Carli F. Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia. Regional Anesthesia and Pain Medicine 2009, 34(6), 542-548.
Glucose Control	Insulin should be used judiciously to maintain blood glucose as low as feasible with the available resources.)	To decrease risk of complications and mortality post-operatively.	Sato H, Carvalho G, Sato T, Latterman R, Matsukawa T, Schricker T. The association of preoperative glycemic control, intraoperative insulin sensitivity, and outcomes after cardiac surgery. The Journal of clinical Endocrinology and Metabolism 2010, 95(9).

References

1. T⊘nnesen H, Rosenberg J, Nielsen H J, Rasmussen V, Hauge C, Pedersen IK, Kehlet H. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial British Medical Journal 1999, 318, 1311-1316.
2. Sorensen L; Karlsmark T; Gottrup, Finn M. Abstinence from smoking reduces incisional wound infection: A randomized controlled trial, Annals of Surgery 2003, 238(1).
3. Liang MK, Nguyen MT, Nguyen DH, Holihan JL, Awawadi ZM, Roth JS, Wray CJ, Ko TC, Kao LS. Preoperative glycosylated hemoglobin and postoperative glucose together predict major complications after abdominal surgery, Journal of the American College of Surgeons 2015, 221(4), 854-861.
4. Berger RL, Li LT, Hicks SC, Davila JA, Kao LS, Liang MK. (). Development and validation of a risk-stratification score for surgical site occurrence and surgical site infection after open ventral hernia repair. Journal of the American College of Surgeons 2013, 217(6), 974-982. doi: http://dx.doi.org/10.1016/j.jamcollsurg.2013.08.003
5. Kiecolt-Glaser, Janice K; Page, Gayle G.; Marucha, PT.; MacCallum, RC; Glaser, R.  Psychological Influences on Surgical Recovery: Perspectives American Psychologist 1998, 53(11), 1209–1218.
6. Güenaga KF, Matos D, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery, Cochrane Database of Systematic Reviews 2011 9, DOI: 10.1002/14651858.CD001544.pub4.
7. Kwon S, Meissner M, Symons R, Steele S, Thirlby R, Billinghma R, Flum DR. Perioperative pharmacologic prophylaxis for venous thromboembolism in colorectal surgery. Journal of the American College of Surgeons 2011, 213 (5), 596–603.
8. Buehlmann, B. M. M. D., Frei, R. M., Fenner, L. M., Dangel, M. M., Fluckiger, U. M., & Widmer, A. F. M. M. Highly Effective Regimen for Decolonization of Methicillin-Resistant Staphylococcus aureus Carriers. Infection Control and Hospital Epidemiology 2008, 29(6), 510-516. doi: 10.1086/588201.
9. Tepaske R, Velthuis H, Oudemans-van Straaten HM, Heisterkamp SH, van Deventer SJ, Ince C, Eysman L, Kesecioglu J. Effect of preoperative oral immune-enhancing nutritional supplement on patients at high risk of infection after cardiac surgery: a randomised placebo-controlled trial. Lancet 2001 358 (9283) 696-701.
10. Brady M, Kinn S, Stuart P, Ness V. Preoperative fasting for adults to prevent perioperative complications, Cochrane Database of Systematic Reviews 2003, 4DOI: 10.1002/14651858.CD004423.
11. Noblett SE, Watson DS, Huong H, Davison B, Hainsworth PJ, Horgan AF. Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Disease 2006, 8(7), 563-569. doi: 10.1111/j.1463-1318.2006.00965.x.
12. Hausel J; Nygren J; Lagerkranser M; Hellström, Per M; Hammarqvist F; Almström C; Lindh A; Thorell A; Ljungqvist O. A Carbohydrate-Rich Drink Reduces Preoperative Discomfort in Elective Surgery Patients. Anesthesia & Analgesia 2001, 93(5), 1344–1350.
13. Varadhan, K. K., & Lobo, D. N. A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proceedings of the Nutrition Society 2010, 69(04), 488-498. doi: doi:10.1017/S0029665110001734.
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