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.
Dr. Kelly Mayson
ERAS Quality Improvement
ERAS Quality Improvement