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StayCurrentMD
Update Course Rewind: 2020 ERAS
With Dr. Kurt Heise · hosted by Dr. Todd Ponsky
Part of
Crohn's Disease 11 items
Chapter 1 of 6 · Fundamentals
ERAS introduction
Introduction to ERAS in Pediatric Surgery
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The patient was given protein shakes preoperatively for nutritional optimization.
On the day of operation, the patient came to the hospital drinking high carbohydrate clear liquids, which were stopped one hour before the operation.
Total IV fluids for the case was less than 4 ccs per kilo per hour.
Postoperatively, the patient was put on multimodal analgesia with Tylenol, Toradol, and Neurontin.
The patient was allowed to drink immediately after surgery and started to snack that night.
The patient went home the evening after a partial colectomy.
The institution has a protocol to discharge patients when physiologically ready as opposed to waiting for the surgeon to approve discharge.
Pre-op optimization period and heavy counseling with families about discharge goals is important for setting expectations.
The pain team tried epidurals for about a year but found that patients were slowed down with their discharge, so they changed to QL blocks, rectus sheath blocks, or TAP blocks.
Dr. Heise gave grand rounds to the anesthesia department twice with the chair present to secure buy-in for ERAS protocols.
In the adult population, literature supports that mobilization and early PO intake are the most important drivers to early discharge.
In the bariatric population after sleeve gastrectomy, over half of patients are discharged on the first post-operative day.
With regional blocks and multimodal pain control, big surgeries including colectomies and craniofacial reconstructions can be done without the use of narcotics.
ERAS is a multidisciplinary, multimodal, evidence-based way of delivering care to patients.
The goals of ERAS are to optimize patient physiology throughout the entire perioperative pathway.
The strategy of ERAS is to decrease operative trauma, inflammatory response, and stress.
ERAS tactics include optimizing fluid and analgesia, mobilizing early, and feeding early, which work synergistically.
ERAS outcomes include faster healing, earlier discharge, and fewer complications of all types, not just surgical complications.
When ERAS is done well, it should decrease readmission rates.
Dr. Heise's team at Emory found that ERAS implementation did not slow cases down, contrary to initial concerns.
Over years of ERAS implementation, there were decreases in intraoperative fluids, intraoperative and postoperative narcotics, and time to getting on a full diet.
Dr. Brindle authored a recent paper explaining a neonatal ERAS bundle created from scratch.