ERAS - Clinical Practice Updates

we talked about pain control we talked about this so that brings a perfect segue into our next session uh which is RAS um and so I know we have uh Mary and Kurt already Mary Brindell and Kurt Heist are going to be presenting to us about RAS and uh Mary are you going to be presenting those slides? Yes, I am. All right so uh Mary Brindell um and Kurt Heist we really appreciate you coming on and this is uh a very evolving topic I know it's exploded from me not using it at all to this becoming an everyday thing we talk about Uh so let's let's let's bring it up and see how many people are doing this. All right, I'm going to share my screen. Can people see it? Yep. Okay, great. All right, uh Kurt and I have really been looking forward to this as being uh uh and for a while almost lone pediatric ambassadors to ERS in uh pediatric surgery but this is changing certainly Um those of you who've been doing work in um adult general surgical care uh will be relatively familiar with enhanced recovery after surgery and uh I think this is kind of expanding and increasing in the pediatric surgical world. Uh we figured the very best way of talking about enhanced recovery after surgery in pediatric uh in pediatric general surgery is to really provide a bit of uh a case example. So I'm going to hand this over to Kurt to get us started. Thanks for asking us to come and talk about this. Uh rather than asking you questions about what would you do, I'm going to ask you questions after I present the patient about why don't you do this? And so Mary's going to show you the uh MRE of the Crohns patient that we'll present. Who here um in the faculty, how many of you are using ERS protocols at your hospital now? How about how many have tried? How many have tried? So you tried and abandoned it Mac? You have to get a lot of people engaged as they're going to tell us. So Todd, this is a super good question because uh whole just published a paper recently about um multi-disciplinary engagement and how important it is. We'll come back to this in just a second. Okay. You know I'm see this now? No it's perfect. Okay, thanks. So uh JG is uh a 16-year-old gal who has a tight ileocecal uh a tight TI stricture and she's lost some weight uh hadn't been nutritionally managed very well so she was sent to our clinic for um questions about Ile. We gave her an explanation of the operation and then um and also about enhanced recovery. Uh we put her on protein shakes and scheduled her for a few weeks later. Next. Um she was on the day of her operation, she came to the hospital drinking high carbohydrate clear liquids. Um, unfortunately, I got the short straw that day and there was a liver transplant in my room so instead of starting early in the afternoon, she started at 6:00 because RAS was written on the board next to her name, the day surgery nurses gave her clear liquids during the afternoon So and they stopped it an hour before the operation so she came into the operating room well hydrated. She was given a block and pre-op medications next slide. Um and uh she had a single side procedure, uh a RAS anesthesia protocol was invoked and her total IV fluids for the case with less than 4ccs per kilo per hour. When we finished her stable resection, um she we had a closing protocol, changed the instruments and gloves. Uh postoperatively we put on uh multimodal analgesia with Tylenol Toradol and Neroton. Uh we allowed her to drink immediately and she started to snack that night. The following morning uh she was Hep locked and next then she was put on a regular diet, she ate. Um she had good pain control, PT showed up and started to walk her every two hours. We gave her Sena, she had an evacuation. And so at dinner time, the pre-op goals that we had set with her were all made. And so uh she went home that evening um after a partial colectomy. And so um Mac and uh I would just ask you what did you notice about this case? Well the first thing I noticed was the beautiful single sight approach. I'm sure that that's pretty common my my peers so anything else? Or Matt, go ahead. Just just again this worked beautifully. You met all your parameters, the nurses pre-op flexible and and kept the kept the path going. Um uh this is the way it's supposed to work the tap block uh was beneficial. Um I I congratulate you. Well just to be clear, um not everybody goes home in a day at our place uh I had a a 10 day colectomy a couple weeks ago that had complications afterwards. So we have the same challenges you do. But um it is more common uh as you can tell to have people meet their goals early. We had two FAP patients a month ago that went home in two days and after a procctectomy and colectomy. So um why don't you put on the next slide Mary let's just ask people. Um in your hospitals would a patient like this be able to go home on post-op day one. Any takers on that question? Jason, how about you? What do you think? Dan. Any say your hospital while we're waiting I'm going to see who's who's turning off their mutes here. Uh Dan's unmuted. I'll let him answer and then I'll go. So at our institution we've instituted a protocol across all surgical patients, which is discharge when physiologically ready as opposed to waiting for some uh for the surgeon to come by and say yes, you're ready to go home. So my answer for my own personal patient would be absolutely and I've done this, you know, to do the patient when they're ready to go home, you send them home. So uh Dan I think that's a great answer. Let me let me follow up with that by saying have uh have you ever had patients who felt like they weren't ready to go home mentally when physiologically they had met all their discharge goals. Of course. Um I think we probably all have and if it's not the patient it may be the parents and uh I I would suggest that as pediatric folk, we tend to uh we tend to be a little more lenient at least I have been with uh saying sure you want to stay overnight, you can stay overnight, we'll send you home in the morning. So um Mary's going to show an infographic a little bit later during her section. Um you go on Mary the next slide. But uh about 10 years ago the adult enhanced recovery group um did a really nice study where it talked about the parts of the ERS protocol that were most influential and they identified mobilization and oral intake as being the most important after talking with the families about what these discharge goals would be because they found that about half their cases were ready to go home physiologically, one to two days before they actually would agree to go home because they were afraid and so having this pre-op optimization period and heavy counseling is really important. In the Nisqu meeting that's going to be next later in the month we have one of the nurses is going to talk about how she calls them several times during the period before their operation and goes over these things and reassures them that they will be when they meet these goals, they'll be safe to go home. Uh were there any other uh uh things like uh uh Mac, Dan, any others about the getting the patient ready or optimizing the patient. How would this be done at your institution? As I suggested earlier, my institution is is not really latched on yet. Uh requires getting a lot of people in line and uh I've just had some resistance, need to keep working on it. Okay. Do would any of you guys give uh oral supplements beforehand to change the trajectory of their of their uh visceral proteins? Mark, how about you? You do bariatric cases? trying to set me up there, Kurt, so in my in my previous institution we for sure my patient would go home. Uh we don't do uh you know I I the protein supplements ahead of time you and I hadn't really talked about that before, but I think that's just about normal nutrition getting your patient ready for surgery. Uh you don't mention the uh preoperative carbohydrate drink which in my bariatric patients, you know, again, all these, you know, the the ERS and implementing ERS is really a multidisciplinary never. See you really need to get every everyone's buying. One of the hardest things in the obese patients is getting the anesthesiologist buy to giving the the preoperative carbohydrate load. Uh we'd let them, you know, we we'd let them drink up to four hours before but they wouldn't let us get too close. Uh although I think that's subject to change as well. But in our bariatric population after sleeve gastrectomy, we're able to get over half of our patients out on the first post-operative day. But again, I think the preoperative education is key because, you know, like a lot of these patients and a lot of your patients when you do this are going to be like, well, wait a second, you know, I'm not ready up here, not physiologically and having those conversations ahead of time is very important. So one of the things that Mark just brought up which was kind of important in our institution is um after eight years of doing enhanced recovery and not having aspiration events, we uh in our quality council went to the anesthesia teams on all of our campuses and asked them to change our NPO times from this 20-year-old arrangement which said two hours was okay to making it one hour NPO time. So on March 1st uh for all of the 43,000 procedures that are done in our institution on an annual basis, the NPO time for clear liquids became one hour. And that was I think very important because uh both Mark and I have worked on that for quite a while. Uh Mary, why don't you go to the next slide? Okay. Uh so this patient did not get mechanical bowel prep. It just got oral antibiotics on the day beforehand. Um any any takers on that? Obviously we all know that there are meta analyses that suggest that bowel preps can be helpful, also suggests that oral antibiotics can be helpful. I think we've been around and around and around on this and and there. There's a lot of data and a lot of opinions. Okay, fair enough. Next slide. Okay, um so one of the things that I thought you might have uh focused on but didn't was uh the pain team involvement. So early in our practice we uh had a a marginally functioning pain team and we invited them into the ERS club and uh got them involved. We gave them a lot of opportunities to regional blocks and for a year we did epidurals. It was a disaster. The epidurals uh slowed the patients down dramatically so we just went to QL blocks, rectus sheath blocks or tap blocks. Um, and uh once we started doing that, it made it much easier for the patients to ambulate. Um, the question here about the multimodal analgesia. Um, many of the um uh protocols that you'll read about in colorectal surgery have people getting PCAs. By giving the premeds on the morning of the operation or the day before the operation and giving them a block um and then scheduling the medications post-op, we're able to um we're able to do a uh a pretty good job at meeting their pain control uh Mary's going to show you in a minute the uh decrease in narcotic utilization in our institution once this started and that becomes socially a big deal as well. We can do colectomies or uh cranio facial operations with no narcotics becomes really big deal for the family. Mary. So I wanted to uh wrap this up um Todd this is going to blow your mind I'm going to finish before my 15 minutes is up. Oh my gosh. I know I someone protect us here away please. Uh so um the important uh points I wanted to make as we tap the brakes and get ready to shift to Mary's presentation is we spend a fair amount of time on patient engagement. Now, I do a good job of that in my clinical visit but I we have NPs who reinforce this. So as Todd mentioned before, repetition is a learning principle for all of us. Um right at the beginning I gave grand rounds to the uh anesthesia uh um department. I did it twice and um uh the chair was there for these presentations. She was very excited about this and so I got a lot of support right at the beginning. We got one of our superstar NPs to be the queen of enhanced recovery. And so she we got nursing on board and they became quite uh big advocates for it. We changed the NPO time, we did schedule medications and reinforced as Dan said, uh the importance of giving people uh an understanding of what a safe discharge was so that they would not dig their feet in and decide they wanted to stay for a long time. So um anyway, I'll uh I'll pause here at this point and and ask Mary to take over. I thought that was going to be a a great nemonic but it was I tried something so it doesn't I think it's it looks like perf is what it looks like. Right, I think it's it's probably a good time to just sort of quickly go over exactly what enhanced recovery after surgery is. And I think many of us feel that um that we do enhanced recovery after surgery in um some form or another. But if we actually look at it as the as the overall big picture, it's multidisciplinary, multimodal, evidence-based way of delivering care to patients. So the goals are to optimize patient physiology throughout the entire perioperative pathway. The strategies are to decrease um operative trauma, inflammatory response and stress. And that the typical tactics that we use within that are things like um optimizing fluid and analgesia, mobilizing early, feeding early. And these all get bundled up so they act synergistically. Um, so I would say that one of the important things about enhanced recovery after surgery is that the whole of it is greater than the sum of their parts. And the outcomes are that they heal faster, they go home earlier, they have fewer complications. Um, so that's, you know, the overall picture of what that looks like. And the adult world has a huge amount that's published on the benefits of enhanced recovery after surgery. And certainly there are a lot of surgical benefits in terms of complications, but also there's a decrease in non-surgical complications. The um so the parentage of enhanced recovery after surgery often sits in our fast track um surgery programs where there has been uh shown to be reduced length of stay after surgery. Um uh and a lot of the concern has been that this comes at a cost of increased readmission. I think it's one of the benefits of enhanced recovery after surgery is that this kind of holistic process, this involvement, this um focus not necessarily on just getting patients out but on that full spectrum of care, should when done well, decrease the readmission rates. So the question was asked earlier, um do you use enhanced recovery after surgery? And I guess I would open that up to say if you do use it, um, do your patients know that um they're an enhanced recovery after surgery patient? Do the nurses know that they're looking after an ERS patient and do the anesthesiologists are they aware when they're looking after them and do they have a protocol for those patients as well. So I'd be interested in in getting any uh sort of opinions from the group on that. Mary, can you ask the question one more time? Yeah, so the question that I would say is if you are using enhanced recovery after surgery, are your parent are your patients aware of that or their parents? Are the nurses aware of that? And are the anesthesiologist, are they also following enhanced recovery after surgery protocols? Well that actually leads to the point I wanted to make earlier. You know, all the other things we've talked about up until ERS are things that the surgeon can pretty much decide to change their practice. Um, this one not so much. And this is such a a massive team approach that um that's why people struggle with getting it started. Um it's the ultimate in multi-disciplinary change and it's a big change at that. So it has to come from the leadership above where the head of surgery, the head of anesthesia, the head of patient of nursing, the head of patient relations, they all meet together uh to make sure everyone's on the same page. I like to give a carbohydrate drink because I learned from Kurt a few years ago at the update course. I but I'm too terrified to do it because if it happens to be a single anesthesiologist that's on that day and they're not up to speed, then I just totally ruined everyone's day. So I really this is won't happen without a total multidisciplinary approach. Right. Todd, I was going to make the comment to Mary that there's no way that I can use ERS with all without all those other people. Yeah. Being on board and doing ERS. So there's no way a surgeon can do it. Yeah, you know if you have somebody persistent like Kurt, you can get it done and that's what it requires. I mean, Kurt did a fantastic job in in Atlanta where uh he got anesthesia involved and and Kurt actually sort of did it subvertly uh on his own for a few years to and and was collecting his own return to the system and repeat, you know, uh readmission rates so that he could then kind of come up and show us, look, I've been doing this for five years, it's all fine and it all works which was uh really uh an interesting way to do it to just hit us with data because I do think people respond to uh data. Yeah, Saleem's saying Kurt is subversive. Yeah, he can. Mark, Mark, I'll give you an example. You you so I'm going to be the surgeon, I want to push the envelope, I want to try it. I know it's a little risky because whoever's on that day may say no. I need to know there's a number to call like you that would that would I would feel safe that I know if I get there the morning of and the anesthesiologist says no, I can call the Mark Hotline and I know I don't have to worry about it because you would overrule it. I would have to know that that leadership came from above. Well, you can't do it without involving everybody. So it's sitting down with the nursing manager on the floor. It's sitting and we even had got epic involved because we on the OR board, there's a little icon in Atlanta for ERS so that everybody knows the patient's on ERS. So once it becomes institutionalized, then you can you can do that. And so if you have the rogue anesthesiologist that's like, you know, wait a second, we're not doing this. It's like, wait a second, your chief of anesthesiology said that this is okay, you've been this has been communicated to you. We all know about this. If you're not willing to do it, we'll find someone who is. And I think Yeah, what everyone's saying I think is exactly what what Kurt and I would, you know, we're hoping we're hoping to hear is that yes it does require you to be a champion but you absolutely cannot do this alone. No matter how much passion you have for enhanced recovery after surgery, it has to be a team sport. So we we collected data for six months on the uh one hour NPO time. And then Todd just like you, the people at our institution were anxious that if a patient misbehaved or something like that that it would slow the cases down and they'd be behind but but we found the data was the opposite is that if you made a point of, you know, in my office I make the parents raise their right hand and say, I promise I will give my kid a Gatorade while I'm driving to the hospital because sometimes they think it's such a suggestion, okay? And when they agree to do that and we make sure that it's not coffee with cream or they're giving the kid or then then we didn't have any delays during that time and so that was that that really captured people's attention and got them on board. And I will say that that data is really valuable in getting this going. I think Mark it was you who said that. Um, and I think even things like um the surgeon will remember that one single case where they had a delay because their patient was given fluids within the hour. Um it should be rare if you've got a good system, um but if you actually have good data to show them how it's actually working, a lot of the times you can get people on board. And um I also feel that it's really important and and this is why I have this slide up to show people uh the overall impact. So not even just to rely on the studies that are out there, but to actually show the difference because as you implement enhanced recovery after surgery and this is a study that was done by uh Kurt and Mulan uh and his team in Emery that over the course of years with um additional ERS elements that were adopted, um additional work for implementation that there's decreased interoperative fluids that are given, decreased uh intraoperative and post-operative narcotics, decrease time to um getting on a full diet and along with that these patients get better faster, they're happier, they go home quickly. Um and I think that's uh that data really does speak for itself. I'm going to switch gears, um a little bit, skip to uh 30,000 foot view and this case I'm going to actually uh change the patient to actually being your center itself. So this really could be any uh neonatal surgical center but let's say that it's yours. And you are looking at your patients who undergo abdominal surgery, you think that they're actually doing pretty well. Um, but you decide to look into it. You've got uh NIS quip running. So you pull up your results and you get a little bit disappointed to see you first look at your SSI rates and you realize that you are a significant outlier at your your center, that your center has very high SSI rates and you look into it and then you realize that your patients are staying long in hospital. You go to the Nick you and you realize that they're being ventilated longer, they're not feeding quickly. You're more and more discouraged. Um, you talk with the nurses, they say there's just poor communication between teams and the practices that you thought were being followed are really not being carried through the way you thought they were. And I'm going to pause here and say that this probably occurs at way more centers than we're aware of. Um, we often feel like we're we're doing uh the right thing by our patients um and that our practices are good, but there's a lot between us uh knowing that we should be doing something and that patient actually receiving um that treatment. So I guess I'd pause here by saying you know what what is the problem with a unit like this and how do you fix it? Um, do you develop a pathway for those neonates that are undergoing GI surgery? Do you do you choose a few practices and adopt them across all surgical neonates to improve care? Do you try to do some type of combination of the two? And I'd be interested to see. I'm sure other other folks have um identified problems in their neonatal surgical units and and what sort of approaches have you taken? So Mary, there's uh uh Dr. Durham could talk a little bit about this. We began to use enhanced recovery in our newborns um and found that the uh kids with motility problems like an imperforate anus, um all the other enhanced recovery principles worked well, but feeding them immediately was not a great idea. The uh there is a uh paper and publication in JPS right now on dudal Treachery repairs and enhanced recovery that shows that they uh have an excellent uh return rate, recovery rate and without a increased return rate. So it there are neonatal things that can be done uh to help this and I that that's the softball I'm throwing to you so you can hit it out of the park with your neonatal. Yeah. Um, well, I I figured this would be a a good time to share our um neonatal intestinal surgery enhanced recovery after surgery protocol. And this has just been published uh a little bit earlier this year. Um, it's one that was built from scratch. Um, there's a number of elements that would look similar to adult uh ERS protocols, um but uh these were really generated individually and evidence-based. You can kind of see especially if you start using these how a lot of these various elements end up working together. Um, they work synergistically and you also realize once you start using these that it is exceptionally hard to limit this type of uh practice to the subset of patients for which you initially intended to use it. So if you're targeting infants who are undergoing intestinal resection surgery and you start developing care pathways that are opioid sparing, for example, um the other patients who are undergoing surgery will often end up benefiting from from this type of thing as well. And once you start having teams that get invested in this, um they naturally want to start adopting other elements of enhanced recovery after surgery care. And I actually feel like opioid sparing analgesia is a really good one to to think about because I actually feel this is one of these areas where um many of us, many of our centers could probably still uh do with a little bit of improvement. So I'd ask um this is a very simple question, do you usually treat neonates with opioids after they undergo GI surgery? This is in the post-operative period. Um, so I I send that out we could uh, you know, we could for example uh this might be a good time to do a show of hands uh for those of you who are on zoom with us. Um, and so this is just typically, so do you typically treat neonates with opioids after intestinal surgery. Hands up those who do.