Enhanced recovery programs aim to return patients to normal life function as soon as possible following surgical and other procedures. To accomplish this goal, enhanced recovery programs are founded on a bedrock of patient education. The four main strategies are early feeding, early mobilization, goal-directed fluid therapy, and limitation of opioid analgesic agents. Within each of these strategies there are multiple tactics that can be employed. It is hoped that the following set of frequently asked questions and responses will help safely and effectively develop enhanced recovery programs.
- Carbohydrate loading â When? Where? Why? And How?
- When? Most studies that show benefit to preoperative oral carbohydrate loading suggest that it should be performed within 12 hours of surgery to help to maintain insulin sensitivity and blood sugar control during the early postoperative period. 50 to 100 g carbohydrate loading can be done on the evening prior to surgery and early in the morning on the day of surgery. Some programs find it simplest to instruct patients to carbohydrate load before going to bed on the evening before surgery and once again as soon as they wake up in the morning on the day of surgery. It is important to note that some patients may have contraindications to receiving fluids within a few hours of anesthesia (add link to âreduce perioperative fastingâ section). Specifically, patients with documented delayed gastric emptying, motility disorders (eg achalasia), obstruction, and possibly those undergoing gastroesophageal surgery may not qualify.
- Where? As stated above, most carbohydrate loading is done before the patient comes to the hospital for surgery. As such, it is helpful to have consensus between surgical and anesthesia providers on a carbohydrate loading plan that can be communicated to patients both verbally and in writing.
- Why? We would never ask an athlete to enter a race in a starved state yet out patients traditionally encounter the significant physiologic stress of surgery after an overnight fast, contributing to a catabolic state. Oral carbohydrate increases insulin levels preoperatively to allow patients to enter surgery in a metabolically fed condition. From a research standpoint, carbohydrate loading has been shown to decrease insulin resistance and protein breakdown, helping to maintain muscle strength.
- How? The best product for carbohydrate loading remains an area of significant research and debate. The research supporting the benefits of carbohydrate drinks used complex carbohydrate (maltodextrin), which results in a greater insulin response than simple carbohydrates (like fruit juices). There are a number of specifically made commercial products available. Some question whether these products have significant advantages over simple, less expensive beverages, and larger studies are required.
- Multimodal non-opiate analgesia strategies
- What are the types of analgesia medications that are commonly used? Many enhanced recovery programs believe that the one of the main mechanisms of action for success is reduction of narcotic opiate medications, which are associated with multiple side effects and immunosuppression.Â There are multiple non-opiate oral and intravenous medications that have been used to supplement or replace the need for traditional narcotics.Â In general these can be classified under the categories of NSAIDs, COX2-inhibitors, gabapentinoids, opiate-like analgesics and acetaminophen.Â Each of these drug classes and agents has unique risks, benefits and dose limitations.Â Although inclusion of non-opiate medications is encouraged, each program should carefully review these considerations in collaboration with pharmacy support.Â Patient education regarding each of these agents has been shown to significantly improve compliance.Â Lastly, non-medical strategies for anxiety reduction and analgesia, including ice-packs, acupuncture, and massage therapy may assist, as well.
- What is the role of regional blocks? Similar to the discussion regarding utilization of non-opiate analgesics, many enhanced recovery programs believe that targeted utilization of regional blocks helps to achieve the goal of narcotic reduction.Â These blocks may take the form of catheter based therapy, including epidural catheters and regional infusion pumps.Â More commonly, they take the form of infiltrative one-time blocks with medium to long-acting anesthetic agents, particularly in cases where a minimally invasive surgical approach is being used.Â Site-specific expertise from pain medicine and anesthesia providers should be sought to marry regional anesthesia pathways to enhanced recovery programs.
- What does early mobilization mean? Early mobilization is a core component of all enhanced recovery programs. The ability to be out of bed and to ambulate is a strong marker of successful early recovery and is believed to prevent complications, including pneumonia and VTEs.Â Common goals include sitting up on the side of the bed or in a chair on the evening of surgery and ambulating at least four times per day thereafter.Â Other programs prescribe a certain number of hours out of the bed per day.Â The keys to successful implementation of these strategies are to once again educate patients regarding activity minimums/expectations, have excellent pain control, minimize drains and catheters, Â and be in collaboration with nursing and physical therapy team members.
- What is goal directed fluid therapy? Many enhanced recovery programs refer to âfluid restrictionâ as a core component of their programs.Â This concept evolved from recognition that volume overload during and after surgery is common and deleterious.Â However, arbitrary fluid restriction can also have deleterious effects.Â Instead, individualized âgoal-directed fluid therapyâ is the preferred concept.Â Intraoperatively, there are various methods by which anesthesia can measure volume responsiveness and should aim to maintain adequate perfusion with the minimum volume of fluids possible, maintaining a buffer of safety in case of bleeding or other sudden events.Â Pneumoperitoneum, which reduces cardiac preload poses special challenges in this regard.Â As always, solid communication between surgical and anesthesia teams is the best strategy to obtain safe and effective fluid administration during surgery.Â After surgery, patients without oral intake may need a low rate of maintenance fluids.Â Again, these fluids should be tailored to the patient aiming for adequate end-organ perfusion.Â Trainees need to be instructed that bolus fluid administration should be reserved for patients with altered vital signs or persistent low urine output.Â Serum BUN, creatinine, and BNP measurement may further guide postoperative fluid therapy.Â One useful strategy is to saline lock fluids as soon as patients are able to support their oral intake with >600 cc PO.Â This tailored approach is more safe and effective than an arbitrary discontinuance of fluids on a given postoperative day or time.
See examples of ERP pathways used by SAGES SMART members.