Treating the patient throughout the surgical process using evidence-based practice
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Surgical care often is based on learned protocols that are not necessarily based on science.
Enhanced recovery after surgery (ERAS), however, uses multidisciplinary standardized plans of care composed of evidence-based interventions throughout the operative process. The goal of ERAS is to improve the quality of patient care and to accelerate the recovery process.
A group of European academic surgeons — the ERAS Society — developed the concept of ERAS in 2001 and continues to publish evidence-based guidelines. The ERAS Society has accredited one U.S. center as an ERAS center of excellence — Levine Cancer Institute of Atrium Health — with plans to accredit additional centers in the U.S.
ERAS protocols start in the preoperative phase, extend into the operative arena, and continue in the postoperative and recovery phase. These protocols can be especially helpful to APPs caring for surgical patients in the oncology setting.
Preoperative ERAS
APPs can utilize preoperative ERAS to optimize pre-existing health conditions among their patients.
During preoperative ERAS, we counsel patients to stop alcohol intake 4 weeks prior to surgery. This is due to the increased risk for bleeding; increased risk for wound infection; and impairment of the metabolic stress, cardiac and immune function. Smoking cessation 4 weeks prior to surgery also is encouraged, as smoking impairs wound and tissue healing.
Patients with anemia of chronic disease receive blood transfusions and are started on supplemental iron, folate and vitamin B12. We optimize management of chronic medical conditions — such as cardiovascular disease, chronic obstructive pulmonary disease, diabetes and malnutrition — through referrals to these specialties.
Traditional fasting after midnight the day of surgery increases insulin resistance and patient discomfort and decreases intravascular volume. Under ERAS protocols, patients drink a complex carbohydrate drink the night before surgery and another 2 to 3 hours prior to surgery. Solid foods are allowed up to 6 hours and clear liquids up to 2 hours prior to surgery.
This carbohydrate loading reduces the catabolic state, leading to the release of glucagon and cortisol. Carbohydrate loading increases insulin levels, thus reducing postoperative insulin resistance; maintains glycogen reserves; decreases protein breakdown and maintains muscle strength.
Perioperative ERAS
Glycemic control is important to reduce insulin resistance, as blood glucose levels increase during and after surgery.
Hyperglycemia is dependent on the patient’s metabolic state (fasting, diabetes, etc), the type of anesthesia administered and the severity of the surgical tissue trauma. Even moderate increases in blood glucose are associated with adverse outcomes. Insulin drips often are initiated in the operating room and continued for the first 24 hours after surgery.
Routine use of nasogastric tubes (NG) should be avoided and the tubes should be removed prior to the patient leaving the operating room. Avoidance of NG tubes is associated with earlier return to bowel function, whereas fevers and oropharyngeal and pulmonary complications occur more frequently among patients with NG tubes.
ERAS protocols dictate that active warming devices be utilized in the operating room for cases lasting more than 30 minutes. Several meta-analyses and randomized controlled trials have shown that preventing hypothermia during major abdominal surgery reduces wound infections, cardiac complications and bleeding and improves immune function.
Anesthesia’s use of the bispectral index allows titration to the minimal amount of anesthesia to avoid complications, especially for the elderly. This reduces the amount of anesthetic, minimizes anesthetic side effects, and facilitates rapid awakening and recovery.
Postoperatively, high inspired oxygen is used short term to overcome hypoxic episodes and to preoxygenate/denitrogenate the lungs. High inspired oxygen also protects against surgical site infections.
Postoperative, recovery ERAS
The goal of IV fluid postoperatively is to maintain a zero-fluid balance. Crystalloid excess increases the risk for pulmonary complications and prolonged ileus. ERAS protocols encourage early oral intake beginning the evening of surgery.
Thoracic epidural analgesia (TEA) — the gold standard for abdominal surgery — works best with a dedicated pain service. TEA is associated with return of bowel function, reduction of insulin resistance, and decreased cardiovascular and respiratory complications. Scheduled NSAIDs, COX-2 and acetaminophen reduce opioid use and opioid side effects. Nursing interventions such as heat packs and splint pillows for pain relief also are encouraged.
Early mobilization should begin on the day of surgery. Patients and family members need to be educated on postoperative activity in the preoperative phase, as patients and families think that the patient is too sick to get out of bed. For those patients with a sedentary lifestyle, preoperative physical activity should be encouraged.
Promoting patient care
ERAS is a multidisciplinary clinical pathway that promotes quality of patient care throughout the perioperative process.
Each component of the pathway is based on current evidence-based practice. Education for patients and their families in the preoperative phase is key for successful implementation of the protocol.
The role of APPs is to assess the patient and to implement ERAS protocols. Any patients that become hemodynamically unstable should be removed from the ERAS protocol. Patient care is then individualized to best address the their care needs for recovery.
References:
Aviles C, et al. Clin J Oncol Nurs. 2017;doi:10.1188/17.CJON.466-472.
Bakker N, et al. Surgery. 2015;doi:10.1016/j.surg.2015.01.016.
Bohnenkamp S, et al. Oncol Nurs Forum. 2014;doi:10.1188/14.ONF.434-437.
Brady KM, et al. AORN J. 2015;doi:10.1016/j.aorn.2015.08.015.
Chand M, et al. Int J Surg. 2016;doi:10.1016/j.ijsu.2015.11.047.
Committee on Gynecologic Practice. Obstet Gynecol. 2018;doi:10.1097/AOG.0000000000002819.
Conchin S, et al. Asia Pac J Clin Nutr. 2013;doi:10.6133/apjcn.2013.22.2.12.
Gemmill EH, et al. Ann R Coll Surg Engl. 2015;doi:10.1308/003588414X14055925061630.
Gerritsen A, et al. HPB (Oxford). 2014;doi:10.1111/hpb.12197.
Gustafsson UO, et al. World J Surg. 2013;doi:10.1007/s00268-012-1772-0.
Hain DJ and Kear TM. Nephrol Nurs J. 2015;42(1):11-21.
Hwang SE, et al. Korean J Hepatobiliary Pancreat Surg. 2014;doi:10.14701/kjhbps.2014.18.3.84.
Joliat GR, et al. Br J Surg. 2015;doi:10.1002/bjs.9957.
Kapritsou M, et al. Gastroenterol Nurs. 2014;doi:10.1097/SGA.0000000000000049.
Lassen K, et al. Clin Nutr. 2012;doi:10.1016/j.clnu.2012.08.011.
Lassen K, et al. World J Surg. 2013;doi:10.1007/s00268-012-1771-1.
Ljungqvist O, et al. JAMA Surg. 2017;doi:10.1001/jamasurg.2016.4952.
Mahmoodzadeh H, et al. Surg Today. 2015;doi:10.1007/s00595-014-0937-x.
Lui X, et al. PLoS One. 2014;doi:10.1371/journal.pone.0112062.
Meyer LA, et al. Obstet Gynecol. 2018;doi:10.1097/AOG.0000000000002735.
Montgomery R and McNamara SA. AORN J. 2016;doi:10.1016/j.aorn.2016.10.012.
Moya P, et al. Medicine (Baltimore). 2016;doi:10.1097/MD.0000000000003704.
Nikfarjam M, et al. JOP. 2013;doi:10.6092/1590-8577/1223.
Nussbaum DP, et al. J Surg Res. 2015;doi:10.1016/j.jss.2014.06.036.
Pearsall EA, et al. Ann Surg. 2015;doi:10.1097/SLA.0000000000000604.
Pdziwiatr M, et al. Int J Surg. 2015;doi:10.1016/j.ijsu.2015.06.087.
Rohatiner T, et al. Am Surg. 2012;78:1147-1150.
Teeuwen PH, et al. J Gastrointest Surg. 2010;doi:10.1007/s11605-009-1037-x.
Varadhan KK, et al. Clin Nutr. 2010;doi:10.1016/j.clnu.2010.01.004.
Wallström A and Frisman GH. J Clin Nurs. 2014;doi:10.1111/jocn.12258.
Yeung SE, et al. Am J Clin Nutr. 2017;doi:10.3945/ajcn.116.148619.
For more information:
Lisa Parks, MS, APRN-CNP, ANP-BC, is an inpatient nurse practitioner in hepatobiliary surgery in the division of surgical oncology at James Cancer Hospital and Solove Research Institute of The Ohio State University Wexner Medical Center. She can be reached at lisa.parks@osumc.edu.
Disclosure: Parks reports no relevant financial disclosures.