Title: Enhanced recovery in colorectal anaesthesia
Dr Farooq Brohi
North Tees & Hartlepool NHS Foundation Trust, UK
Abstract: Patient’s journey starts from screening through Preassessment to surgery to postoperative management and finally discharge home. Prior to surgery patients must be fully informed about their disease, treatment options, surgery and anaesthesia. Their general condition must be assessed and plans put in place to improve their health and optimized for surgery. Prehabilitation programme, nutrition and correction of anaemia will help achieve in optimizing.
Measures must be placed to achieve euvolaemia, this can be achieved by various measures e.g. avoiding bowel preparation, allowing clear fluids up to 2 hours prior to anaesthesia and surgery. Preoperative carbohydrate loading helps improve body reserves to cope with stresses during perioperative period.
Use of short-acting anaesthtics in appropriate doses will improve recovery and reduce postoperative delirium. Goal directed fluid therapy (GDFT) should be adopted in high risk patients intraoperatively to maintain fluid homeostasis avoiding fluid excess and organ hypoperfusion. Monitoring temperature is important to avoid hypothermia, which is not desireable. Minimally invasive surgery has clear advantages for improved and more rapid recovery, reduced complications including wound infection, incisional hernia and adhesions.
Postoperative nasogastric tube should not be used routinely. Apply multimodal analgesia for pain control and use of opioids should be minimized. Prophylaxis against deep vein thrombosis is essential element and prevents risk of pulmonary embolism. This can be achieved by mechanical and pharmacological prophylaxis, good hydration and early mobility. Net ‘near-zero’ fluid and electrolyte balance should be the target.
Attempts should be made to prevent postoperative ileus by using multimodal approach to pain relief thus limiting use of opioids, minimally invasive approach will help reducing the requirement for analgesia. Early mobilization, eliminating routine use of NG tube and use of GDFT, all help in preventing development of ileus. Nutritional support should be provided to all patients and oral intake encouraged early. Early mobilization through patient education and encouragement is an important component of enhanced recovery; prolonged immobilization is associated with a variety of adverse effects.
Audience Take Away:
Planning: At our hospital we keep our practice up to date depending on recent advances, evidence available, results of our own practice in perioperative medicine.
Audit & Service Evaluation: Data collection and PDSA cycle (Plan-Do-Study-Act) is very important to reflect on outcomes both good and not so good. This helps to improve patient care and service provided.
Engaging: Regular meetings with members of the team involved (Preassessment, Theatre, Nursing, Surgical, Anaesthetics, Ward, Critical Care, Dietetics) and most importantly patients who have had major bowel surgery done to share their experience.
Research: Look for research opportunities (your own or portfolio studies). Currently we are:
- Recruiting for ALLEGRO (study of intravenous lidocaine for postoperative pain relief in laparoscopic bowel surgery patients)
- Applied for MET-REPAIR (Research on patient’s functional capacity and outcome)
- Designed our own project – Study on dosing of Intrathecal Diamorphine Analgesia in Laparoscopic Colorectal Surgery. Working with Research Design Service at the moment.
Dr Farooq A Brohi, Consultant in Anaesthesia & Intensive Care Medicine at North Tees & Hartlepool NHS Foundation Trust. Roles include: Lead clinician for Colorectal Anaesthesia, Sepsis lead, Research lead. Locally, worked with colorectal surgeons and their team to establish a colorectal team including all members of staff involved in caring for patients undergoing colorectal surgery.
Since 2013 we have established Colorectal Anaesthesia Group (www.colorectalanaestheia.com). This group organizes annual meeting in Manchester, UK in the month of April and a satellite meeting in autumn the various parts of UK.