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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, preoperative 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, major gynecology oncology cases in October 2016, liver resections and pancreatic resections in February 2018, gastrectomy cases in August 2019, and spinal instrumentation and retroperitoneal lymph node dissection in December 2019. We will be launching Nephrectomy and Nephroureterectomy next.

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 vomiting 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 a pre-habilitation/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 ERAS patients to detect undiagnosed diabetic patients, and to identify patients who require improved glycemic control prior to the OR date. We are in the early stages of starting to screen for frailty as well.

Through our patient education booklets we are 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 have also created an ERAS website for surgical patients to access resources. 

In order to promote consistent understanding and sustainment of ERAS within VCH, we are in the process of finalizing an online ERAS learning resource for surgical residents, nurses, and allied healthcare professionals to utilize.

Contact information

Dr. Kelly Mayson
Anesthesiologist
kelly.mayson@vch.ca 

Amy Myring
ERAS Quality Improvement Coordinator      
amy.myring@vch.ca                                                

Julie Nakahara                                            
ERAS Quality Improvement Coordinator                                             
julie.nakahara@vch.ca