Table 1 Protocol characteristics of the followed enhanced recovery program
From: Enhanced recovery in colorectal surgery: a multicentre study
Time | Procedure |
|---|---|
Preoperative | a. Provision of verbal and written information to patients regarding the ERAS. Collection of signed consent. |
b. Malnourished patients to receive hyperproteic supplement at least twice per day during the week before surgery. | |
Day before surgery | a. No colon preparation. |
b. Normal food in the morning. Liquids on demand during the evening. Four bricks of carbohydrate-rich Nutricia Preop® to be taken during the evening (total: 800 ml). | |
c. Prophylaxis for pulmonary thromboembolism following normal practice. | |
d. Antibiotic prophylaxis following normal practice. | |
Day of surgery (before surgery) | a. Two hours before surgery: provision of two bricks of Nutricia Preop® (total: 400 ml). |
b. Antibiotic prophylaxis. | |
Operating room | A. Surgeons: no drainage; nasogastric tube, if needed, to be removed before extubation; if possible use transverse or curved incisions in open surgery. |
B Anaesthetists: | |
-Maintenance: Oxygen/air with FiO2 >80%. | |
-Monitoring: routine. Only use arterial/central catheter if unavoidable. | |
-Fluids: maintenance with Hartmann (5 cc/kg/h). Bolus of gelofusine (250 cc). | |
Maintain Hb > 8.0 g/dl. | |
- Optimise stroke volume via oesophageal Doppler: | |
-250 cc of fluid in bolus; if SV > 10% repeat until this figure is not reached. Provide no further bolus unless SV falls or there is blood loss. | |
-If hypotension remains after SV correction, use a vasoconstrictor. | |
-Consider use of inotropic agents if peak velocity descends and clinical signs suggest ventricular function deficit. | |
-Temperature: use liquid heater and heating blanket. | |
Day of surgery (recovery room) | -Mask with high oxygen flow for 2 h independent of saturation. Follow with nasal cannulae to maintain SpO2 > 95%. |
-Maintain mean blood pressure >65 mmHg. If blood pressure low provide 250 cc gelofusine and reassess. | |
Day of surgery (ward) | -In the evening sit patient in seat for at least 2 h. |
-Liquid diet (800-1000 ml). Include two bricks of high protein/high calorie hospital dietary preparation (specific for postoperative period). | |
-Minimum diuresis (500 cc in first 24 h). | |
-Analgesia: 1 g paracetamol/6 h. | |
Postoperative day 1 | -Liquid diet, at least 2 l, including 3 bricks of high protein/high calorie hospital dietary preparation. |
-Mobilisation; patient seated at least 6 h per day. | |
-Suspend IV fluid if tolerated. Heparin injection for maintaining patency of intermittent infusion devices. | |
-Maintain epidural analgesia pump if one in place. | |
-Paracetamol 1 g/6 h. | |
-Lactulose 1 sachet/12 h (preferably magnesium-based). | |
-Assess meeting of discharge criteria: only oral analgesia, mobilisation reaching presurgical level, toleration of solid food, gases passed, stools passed, no nausea, and patient agrees to discharge. | |
Postoperative day 2 | -Suspend epidural catheter; begin with NSAIDS; diet soft/normal; mobilisation on demand; remove urinary catheter and assess meeting of discharge criteria. |
Postoperative day 3 | -Check general status; assess meeting of discharge criteria and take decision in this respect. |
Follow up | -Telephone monitoring for 48 h. |
-First out-patient visit 10-14 days after surgery. |