51������

Ruchir Gupta, MD

   On January 1, the Department of Anesthesiology, in conjunction with the Department of Surgery, will launch the "Enhanced Recovery After Surgery (ERAS) for Colorectal procedures" initiative at Stony Brook University Hospital. This is a multidisciplinary program that brings together physicians, nurses, pharmacists, and nutritionists to provide a seamless perioperative experience aimed at best practices to promote rapid recovery and quicker return of baseline function while minimizing complications.
   The ERAS experience will begin in the surgeon's office, where the surgical department will introduce the patient to the concept of ERAS and provide the patient with a personalized "patient diary" that will educate the patient about ERAS. The patient diary will also contain checklists for the patient to fill so that they can log in important compliance information such as ambulation, smoking cessation, and nutritional information. The surgeon's office will also provide the patient with a "carbohydrate beverage," which would be taken the night before and the morning of the surgery. The literature supports that a preoperative carbohydrate beverage taken the morning of surgery reduces postoperative insulin resistance, hypotension on induction, and overall fluid status. Furthermore, these beverages are considered "clear liquids," so their ingestion 2 hours prior to surgery does not increase the risk of aspiration.
   From the surgeon's office, the patient's ERAS experience moves to the preoperative surgical clinic run by our very own, Dr. Deborah Richman. Here, the patient will be further educated on the patient diary and its various components. Reasonable expectations with respect to pain, ambulation, and PO intake postoperatively will be reviewed. Specifically, the patient will receive more detailed information regarding nerve blocks, whether they qualify for an epidural, and when they are expected to begin PO intake.
   On the day of surgery, the patient will be expected to have taken their preoperative beverage prior to arrival to the hospital. Compliance with "preoperative instructions" related to beverage consumption and surgical site infection guidelines (which were presented to the patient at the surgeon's office previously) will be reviewed. In the preoperative holding area, the patient will receive gabapentin and depending on their surgery, possibly an epidural. Intraoperatively, the patient will receive multimodal pain management techniques which consist of IV Tylenol and IV Caldalor. The patient's fluid management will be guided via the cheetah cardiac output monitor to employ goal directed fluid therapy (GDFT). Postoperative nausea and vomiting prophylaxis will be accomplished via the scopolamine patch preoperatively, and ondansetron and dexamethasone intraoperatively.
   In the PACU, the patient will receive the next dose of gabapentin, IV caldalor, and IV acetaminophen as per dosing guidelines. The patient's epidural infusion, assuming an epidural was placed, will continue. The patient’s intravenous fluids will be limited to “KVO – Keep vein open.”
   The next destination on the patient's journey will be the medical floors where in the subsequent days, the patient will be encouraged to ambulate and begin clears on postop day 1. The goal is to discharge the patient once the patient's pain can be managed with just PO medications, the patient can effectively ambulate, and the patient has no significant symptoms of nausea/vomiting.
   To achieve the goals of ERAS, an immense level of cooperation is required between the various members of the ERAS team. For the anesthesia personnel (attending physician, CRNA, resident) assigned to the colorectal, it is imperative to be knowledgeable about the various elements of the patient's ERAS journey. To care for a patient within an ERAS framework is akin to carrying a baton and care must be taken to ensure continuity of appropriate medical care. Specifically, goal directed fluid therapy is a very new concept to many in our department and adhering to its principles may be challenging in the beginning. For the most part, intraoperative anesthesia care will be protocolized but if there are areas where the clinician feels deviation from the protocol is necessary, a thorough analysis of the situation should be made and the deviation should be recorded and discussed with more senior members of the ERAS program (Drs. Gan and Bennett-Guerrero).
   Lastly, the ERAS protocol will be amended from time to time based on the data obtained and new findings in the literature. Thus, every clinician working with the ERAS colorectal patients is in a position to contribute their findings to the other members so that the best practices can be incorporated into the protocol for future use.