Enhanced Recovery for Colorectal Patients

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1 Enhanced Recovery for Colorectal Patients Caroline Jenkins and Inge Bateman Department of Anaesthesia, Worthing Hospital Western Sussex Hospitals NHS Trust

2 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

3 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

4 Do you do ER? If so what approach do you use?

5 Enhanced Recovery Henrik Kehlet Denmark 1990s Delivered in UK since the early 2000s Kahokehr A, Sammour T, Zargar-Shoshtari K, Hill AG

6 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 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.

7 Oral Nutrition Audit Pre-admission Counselling No Bowel Prep CHO load Pre-op fasting Catheters Premedication Gut motility PONV Enhanced Recovery after Surgery NG Tubes Opioid sparing Analgesics Anaesthetic Mobilisation Fluids Temperature Incisions Adapted from Fearon et al 2005

8 Different Approaches to ER Epidural Spinal PCA Oral analgesia TAP blocks Local infiltration Ketamine

9 Benefits of Epidurals Thoracic is the classic approach Reduction in pituitary, adrenocortical & sympathetic response Opioid sparing Does not modify immunological or inflammatory response

10 Problems Associated with Epidurals Hypotension Fluid overload Slower to mobilise and eat Longer length of stay Failure

11 Benefits of Spinals Improved mobilisation Reduced opioid requirement Fewer complications than epidurals

12 Problems Associated with Spinals Risk of exaggerated cardiovascular changes Risk of high block

13 What we do in Worthing Pathway of a typical ER patient

14 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

15 Pre-op Assessment Standard including bloods/ecg ERP Nurse facilitator present ERP explained => clear expectations Ileostomy information offered Discharge planning commenced

16 Admission Night Before Bowel preparation Carbohydrate drink 800mL midnight Access to water until 6.00am

17

18 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

19 Benefits of Ketamine Opioid sparing Reduces PONV Zakine et al Anaesthesia and Analgesia Vol 106 (6) June

20 Problems Associated with Ketamine Optimal regime not established IV preparation unpleasant taste Zakine et al Anaesthesia and Analgesia Vol 106 (6) June

21 Operation Laparoscopic sigmoid colectomy Small incision to remove specimen Duration 150minutes TAP block at the end of surgical procedure

22 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: El-Dawlatly AA et al. BJA 2009;102:763-7

23 Transversus Abdominis Plane Block Sensory supply from anterior rami of lower 6 thoracic nerves Fascial plane between internal oblique & transversus abdominis

24

25

26 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

27 Performing a TAP Block Using Identify landmarks Ultra Sound 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

28 TAP Block Using Ultra Sound

29 TAP Block Using Ultra Sound

30 Performing a TAP Block (blind) 2 pops & a squirt 1. External oblique fascia 2. Internal oblique fascia transversus abdominis plane

31

32 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

33 Post-op Day of Surgery No nasogastric tube, No drain Return to ward Free Fluids resource drinks Out of bed 2 hours

34 Day 1 Post-op Drip down, catheter out Out of bed 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

35 Day 2 Post-op Ward Round - Doing well Eating and drinking Passing flatus Home Follow up by phone calls by ER nurse specialist

36 Recap of Analgesia used for ER Patients at Worthing

37 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

38 Post-op Analgesia Regular Paracetamol 1g QDS PO Regular NSAID PO Ketamine 15-20mg 4 hourly S/L (for 48 hours) Morphine oral solution PRN Occasionally PCA Epidural on indication

39 Programme Figures in Relation to LOS (so far) Mean Median

40 Readmission Rates (so far) 13% 11% 4.8%

41 CHKS Data F.31 Complex large intestine F.32 Very Complex large intestine 2009 Worthing lower lengths of stay than our peer hospitals.

42 No. completed elective cases Department of Health HES Data for elective colorectal resection in England Length of stay by volume of cases, provider prov. to Dec: Colorectal resection Current Worthing ER Length of stay Mean length of stay (days)

43 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.

44 Any Questions??????

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