At VGH we launched an ERAS program for colorectal surgery in November 2013. This was done by creating a multidisciplinary team for which I have been the Anesthesia lead. Standardized pre-printed preoperative and postoperative orders where created as well as a standardized care pathway. We track preoperative, intraoperative and postoperative process measures, pre operative HbA1c, perioperative glucometers, and 30 day NSQIP outcomes, and length of stays.
ERAS protocols have since been developed for radical cystectomy cases in October 2014, and open and laparoscopic major gynecology oncology cases in October of 2016. We are launching ERAS protocols for liver resections and pancreatic resections in February 2018.
Suggested anesthesia protocols have been created with regard to fluid management, and recommendations regarding which patients would benefit from goal directed fluid therapy with the use of stroke volume variation monitoring. Multimodal analgesia with the use of at least two non-opioid modalities is expected for all ERAS cases, as well adequate postoperative nausea and vomitting prophylaxis based on the patient APFEL risk score. All patients are actively pre-warmed, and then warmed with forced air heaters in the operating room. All patients have standardized orders around perioperative glycemic control.
We are currently working on an pre-habilation/optimization program with the focus on recognition and treatment of iron deficiency anemia prior to surgery through our Perioperative Blood Management Program. In addition we are currently ordering HbA1c on all ERAS patients to detect undiagnosed diabetic patients, and to identify patients who require improved glycemic control prior to the OR date. Through our patient education booklets we are promoting empowering patients in Self Management and S.M.A.R.T goals with respect to smoking cessation, exercising and improved nutrition, as well as relaxation techniques to deal with stress. We are in the early stages of starting to screen for fraility as well.
Dr. Kelly Mayson