Enhanced Recovery for Colorectal Patients
Caroline Jenkins and Inge Bateman Department of Anaesthesia, Worthing Hospital Western Sussex Hospitals NHS...
Caroline Jenkins and Inge Bateman Department of Anaesthesia, Worthing Hospital Western Sussex Hospitals NHS Trust
Aims of the Session
Inform you of how we manage analgesia for ER patients at Worthing Hospital
Inform you of what they do elsewhere with reference to analgesia for ER patients Forum for discussion of current practice
Definition ‘An evidence based approach involving a select number of interventions which, when implemented as a group, demonstrate a greater impact on outcomes than when implemented as individual interventions.’ Enhanced Recovery Partnership Programme March 2010
Do you do ER? If so what approach do you use?
Enhanced Recovery
Henrik Kehlet Denmark 1990s
Delivered in UK since the early 2000s
http://www.scitopics.com/Enhanced_Recovery_after_Surgery.html Kahokehr A, Sammour T, Zargar-Shoshtari K, Hill AG
Background of Enhanced Recovery at Worthing Hospital
2007 project team set up for ER, agreed no patient selection (i.e. all inclusive service) 2008 first patients on ER pathway PCA, Paracetamol & NSAID. Epidural on indication. 2009 ER Nurse Specialist appointed TAP blocks, Ketamine, Paracetamol & NSAID, PCA or Morphine oral solution regularly & PRN. Epidural on indication. With review of patients’ requirements for regular Morphine oral solution we changed the regime to PRN only and PCA on indication.
Pre-admission Counselling
Audit
No Bowel Prep
CHO load Pre-op fasting
Oral Nutrition
Catheters
Premedication
Gut motility
NG Tubes
Enhanced Recovery after Surgery
Opioid sparing
PONV
Analgesics
Anaesthetic
Mobilisation Temperature Adapted from Fearon et al 2005
Fluids Incisions
Different Approaches to ER
Epidural Spinal PCA Oral analgesia TAP blocks Local infiltration Ketamine
Benefits of Epidurals Thoracic is the classic approach
Reduction in pituitary, adrenocortical & sympathetic response Opioid sparing Does not modify immunological or inflammatory response
Problems Associated with Epidurals
Hypotension Fluid ‘overload’ Slower to mobilise and eat Longer length of stay Failure
Benefits of Spinals
Improved mobilisation Reduced opioid requirement Fewer complications than epidurals
Problems Associated with Spinals
Risk of exaggerated cardiovascular changes Risk of high block
What we do in Worthing Pathway of a typical ER patient
The Enhanced Recovery Patient Pathway Mr. C.R. 65 years old. 70Kg with a BMI of 24. Surgical procedure: High Anterior Resection PMH: Fit & No medications Non-Smoker
Bowel preparation Carbohydrate drink 800mL midnight Access to water until 6.00am
Surgery day
CHO drink 200mL 2 hours pre-op Theatre 8.00 Standard Anaesthetic Dexamethasone 8mg IV Ketamine 40mg IV Paracetamol 1g IV Diclofenac 75mg IV
Oesophageal Doppler Cardiac monitor
Benefits of Ketamine
Opioid sparing Reduces PONV
Zakine et al Anaesthesia and Analgesia Vol 106 (6) June 2008 1856-1860
Problems Associated with Ketamine
Optimal regime not established IV preparation unpleasant taste
Zakine et al Anaesthesia and Analgesia Vol 106 (6) June 2008 1856-1860
Operation
Laparoscopic sigmoid colectomy Small incision to remove specimen Duration – 150minutes
TAP block at the end of surgical procedure
Transversus Abdominis Plane Block
Ultrasound guided or blind technique Easy to learn Opioid sparing effect for open & lap surgery
McDonnell JG et al. Anesth Analg 2007;104:193-197 El-Dawlatly AA et al. BJA 2009;102:763-7
Transversus Abdominis Plane Block
Sensory supply from anterior rami of lower 6 thoracic nerves Fascial plane between internal oblique & transversus abdominis
TAP Block Using Ultra Sound Sterile Procedure Sterile field U/S probe protected Patient position Needle selection: regional block or Tuohy needles Bilateral blocks 2 x 20mL 0.25%-0.5% chirocaine
Performing a TAP Block Using Ultra Sound
Identify landmarks Advancement perpendicular to skin via Petit’s triangle with classical 2 pops Oblique approach posterior to mid axillary line with real-time ultrasound guidance Tissue compression aids clarity of image Needle tip placement observed Small volume injections assist confirmation of needle position
Performing a TAP Block (blind) 2 pops & a squirt 1. External oblique fascia 2. Internal oblique fascia transversus abdominis plane
Post-op Analgesia
Paracetamol 1g QDS PO Ibuprofen 400mg QDS PO Ketamine 20mg 4 hourly S/L (for 48 hours) Morphine oral solution PRN (no post-op morphine used at all)
Morphine IV rescue analgesia for Recovery – not used
Post-op Day of Surgery
No nasogastric tube, No drain Return to ward 14.30 Free Fluids – resource drinks Out of bed 2 hours
Day 1 Post-op
Drip down, catheter out Out of bed 08.00 3 x 60m walks, Self washing etc. 4 resource drinks Breakfast, lunch, dinner and snacks WR Note – Home later today or tomorrow Acute Pain Ward Round – pain well controlled on mobilisation, deep breathing and coughing
Day 2 Post-op Ward Round Doing well Eating and drinking Passing flatus Home
Follow up by phone calls by ER nurse specialist
Recap of Analgesia used for ER Patients at Worthing
Per-op Analgesia
Epidural on indication Fentanyl Paracetamol IV Ketamine 0.5mg/kg between induction & incision
Morphine NSAID IV TAP block end of surgical procedure
F.31 Complex large intestine F.32 Very Complex large intestine
2009 Worthing lower lengths of stay than our peer hospitals.
Department of Health HES Data for elective colorectal resection in England 2009 Length of stay by volume of cases, provider 2008-09 prov. to Dec:
Colorectal resection No. completed elective cases
200
Current Worthing ER
180
Length of stay
160 140 120 100 80 60 40 20 0 -
2.0
4.0
6.0
8.0
10.0
12.0
Mean length of stay (days)
14.0
16.0
18.0
20.0
Summary Worthing hospital currently use an effective ER regime without use of Epidural, Spinals or PCA that shows reduction in L.O.S and readmissions rates. The research will be started shortly to add evidence to the clinical findings.
