Enhanced Recovery After Surgery (ERAS) Program: Update Course 2016

You guys are just barely awake now. We have one more thing, as Steve Jobs would say. The ERAS concept is really um just applying consistently things that we've known about for 20 years. And so, um, a little bit differently than the other presentations, I'm gonna talk about the why and the what for just a second and entertain whatever questions you can and then talk about what we've learned in trying to start a program and then deal with resistance. So Henrik Kalet is a Danish surgeon who 20 years ago began to talk about why the patient was in the hospital, and he identified a number of things that we knew about but weren't successfully doing on a consistent basis. And so he created an enhanced recovery bundle and he published this article which at the time people probably didn't really believe, but keep in mind this is an open operation. He was doing sigmoidectomies and getting them home with multimodal care within a couple of days. The punchline was that he was doing it with getting them back to work but without a high return to the system rate and with a very low complication rate. And so. Um, I wanted to just highlight what since enhanced recovery may be new to a number of people, I wanted to highlight what all is involved in here. The top box here are just the principles that are pursued. One is an intense effort at trying to empower the patient and engage the patient in their care by giving them a lot of preoperative information in a repetitive fashion. To minimize the trauma, so this is a group who would be very well prepared to do this because minimally invasive surgery is a real hallmark of this. By not bringing a dehydrated patient to the operating room, we are able to individualize fluid therapy and in the operating room give them much less volume than has been given in the past, and the studies that monitor intraoperative fluid administration between traditional care and enhanced recovery care. Uh, identify that a traditional patient will get 3 times the IV volume in the in the OR that an enhanced recovery patient will. By using multimodal care, we're able to give better pain medicines that don't stimulate the m receptor quite so much and cause us to have ileases afterwards, and both those last two points by decreasing the fluid and decreasing the narcotic. Usage make the ileus rate a lot less. Getting the patient out of bed, because you've talked to them about it beforehand, you've given them a goal sheet and you and you remind them again and again. You write boxes on the wall so that they have to check the box and get up out of bed 5 times a day. This is a real incentive for them. We don't fast the patients. The way a traditional program would, we stop solids at midnight but let them drink high sugar, uh, electrolyte solutions until just 2 hours beforehand, and I, I just make the comment that that this is a national guideline that all of our anesthesia colleagues know about, but not many of us do that because they don't want the cancellations for someone who misunderstands. But your anesthesia colleagues understand and agree with this idea of not bringing a dehydrated patient. To the operating room and lastly, minimizing the metabolic and inflammatory stress with a number of different strategies, some of which sometimes includes IV lidocaine. And so these are the outcomes that we want. We're decreasing the complications. We're trying to enhance the healing faster and this is as a patient safety or a quality officer and patient safety advocate. The sooner an IV is out of the patient's hand and the patient is out of the hospital, that patient becomes safer. When you think about the 5 rights in your hospital, the right patient, right dose, right medicine, right mode, and so forth, and right timing, as long as there are humans in the hospital, you're at risk for having an injury. So while complications may be what we're trying to reduce, when we get the patient out of the hospital faster, it makes a huge difference because it makes them safer. And lastly, returning them to function. The adult NisQuit program has 4 phases to this, and one of which is how they're monitoring how fast the patient returns to work. So adult surgeons, specifically colorectal surgeons, have a large number of randomized controlled trials which I'll show you the data for in just a minute. Which demonstrate that this is a really important tool in reducing complications, reducing. Uh, length of stay without causing a return to the system. And so my, my first invitation to you during this talk is to, uh, tonight when it's quiet and you have the choice between watching another night of Olympic gymnastics or something else that look up the EASSociety.org website and there is a wealth of resources there literature, patient education things, and it will give you an oversight that will complement what I've talked about today. Enhanced recovery programs decrease the length of stay, decrease the complications without the increase in readmissions, and While this originally started in colorectal patients, I've been filling Doctor Wilkins's inbox for a while with bariatrics articles that are related to this, uh, Doctor Clifton's inbox with hepatobiliary articles that are related to this, and so this is being spread to other surgical professions. Urologists use this, gynecologists use this. So here is a meta-analysis from adult colorectal surgery that demonstrates that when enhanced recovery programs are used, there's a significant decrease in the length of stay. I'm, I'll show you our data in just a minute. There is a significant decrease in the types of non-surgical complications getting back to VTEs and things like that. By having this protocol, we decrease the health associated complications that occur less urinary tract infections, less VTEs, less surgical site infections, and this comes without an increase in readmissions. So, um, uh, Doctor Raval and Doctor Short wrote this article a little earlier this year which summarized the literature view in pediatrics. It was a very, very short project because there were only, uh, 5 or 6 articles here. Uh, most of them were written by Ben O. Doctor Mathai wrote one of them. And so, uh, we have a little bit of information here. What we understand about this in pediatrics is that. We're seeing a decrease in length of stay. Our complication rate is about the same. We're not having an increase in the return to the system rate. But all these articles were written with only about 5 or about 25% of the components that were actually used in the protocol, so the study didn't really use all the things, the opportunities that they had, whereas the adult programs have somewhere between 17 and 20 steps in their protocol that help move the patient along. Each of these 6 studies only had about 5 of those 20 things. So this is the enhanced recovery website. There's a boatload of resources on it. The punchline is what we're trying to do is get people to use in a consistent fashion the knowledge that we've had for 20 years. So what are the components? This infographic is ubiquitous. It's all over the place and enhanced recovery, and it's easy to find on the website. Um, I have a, uh, I wanted to walk you through those 20 points by just describing a patient and, and, uh, as I was looking at Jason's, uh, slides a little bit earlier, I changed this so that, uh, um, the first patient is a 17 year old gal who came into my office who was, uh, having an outpatient visit and she's there for a consultation. Many of the patients that we'll operate on are kids that are inpatients who've been bleeding, having 2 stools a day, are on Remicade and steroids, and this works for both of them, but the outcomes that we expect or the changes are going to be a little bit different. So here's what the patient would experience when they walk into the clinic. We'll go over the indications for surgery and the operation after we've taught them about that. They go home and one of our nurse clinicians who owns this program contacts them by phone, sends them a number of PDFs or PowerPoints, gives them handouts, gives them scripts for preoperative medications, and reminds them about things they're. Supposed to drink before they come and we've we've streamlined that so that pre-op day surgery isn't torpedoing us as we do this if the patient needs to come to pre-op clinic, we're repeating that many institutions have an individualized patient goal sheet that they hand to them for the pre-op, the inter-op, and the postoperative care, and the patient has to check these boxes as they walk through this process. We give oral antibiotics for colorectal on the day before. Surgery they drink on the way to the hospital and take a pain medicine cocktail which includes in our hospital it's Neurontin and Tylenol. Our adult colleagues across the street add Celebrex to that, and these are large quantities of those drugs. The patient is going to get a thoracic epidural or a tap block depending on whether they have an ileocystectomy or ulcerative colitis type operation. And they get goal directed fluid therapy, which is a dramatic change from what the volume they get. You all know that if you've ever had a procedure that you're puffy after you've had an IV, but you're not puffy after you drank. You know, your glass of water or whatever you had at lunchtime, and the same thing happens to your intestine when this occurs. So limiting the fluid by using Presodex and albumin and so forth helps quite a bit. We avoid narcotics intraoperatively. We give postoperative Decadron and Zofran. If there's a full use, it's taken out right away and there's no NG tubes post op. We feed them and drink them on post-op day zero, give them the scheduled Zofran and pain medicine. We walk them right away. Avoid flubulses. One of the MD Anderson surgeons who does this said that the most important inflection point in their. The program was to prevent the residents from bolusing the patients in the postoperative period because they all gave them fluid afterwards. On post-op day one, everyone's getting either some kind of stimulant and a full diet, and then we have a protocol-based discharge. So there's probably 4 physiologic points to make here and then 1 last point at the end. By changing the fluid and electrolyte management, um. We bring a patient to the operating room without fasting. That allows the anesthesiologist to change their intraoperative anesthesia management. Many people will give a complex carbohydrate in the pre-op area 2 hours beforehand to drive the insulin levels up so that the patient has high insulin levels protectively during the course of the case. We've not traditionally bowel prepped these patients. They're not having. Their bowels not edematous, but we do give oral antibiotics preoperatively. The water and salt overload is avoided, and and we are prehabilitating the patients. We're getting them ready in a positive way. If the adults make them stop smoking and drinking, but in our case we do whatever is necessary to make them the best operative candidate we can. With regard to pain control, either the patient gets tap blocks or mid thoracic epidurals so that we can get the Foley catheter out and they can have excellent pain control. We switch them out pretty early to oral non-opioid analgesics. Intraoperatively, they're getting Presodex instead of uh fentanyl and um and that pretty much summarizes that. By getting the Foley catheters out and the NG tube out, mobilizing them quickly, giving them VTE prophylaxis and oral antibiotic prophylaxis, we drop our healthcare associated complication rate. And lastly, by feeding them early, walking them early, having a standardized discharge protocol, not having drains. And giving them a huge amount of preadmission counseling, they know that they can get back uh to work and to school pretty quickly. So are there any questions about what I've said so far, because I, there's one other segment that really uh deserves to be addressed. Any, yes, OK, go ahead, David. So, uh, maybe 5 or 10 years ago there was a, a kind of a trend towards using beta blockade in the ice. To attenuate stress response that that has not been used here, but one thing some adult programs have used is they've given IV lidocaine. The theme is that when we wound a patient, we are creating inflammation, and by giving a low dose of IV lidocaine, it seems to attenuate this inflammatory response and by doing that, the patients. Recover more quickly. When I presented the patient, uh, the two patients at the beginning, the child who, uh, I saw as an outpatient. Um, had a colectomy and went home on post-op day2 the night of her operation. Uh, I went up to see her and she said, Doctor Heist, the nurses won't feed me. So we gave her a diet. She had a chicken salad, came in the next morning, lipstick, hairbrushed. I'm ready to go home. We have an ileostomy. We want to make sure you're not going to get dehydrated. We kept her another day and she went to a home on post-op day too. The same thing happened when she had her J pouch, an ileostomy, and on the morning after ileostomy closure, she she was ready to go home. So that's one thing with the kind of patient like Jason presented earlier where they've been in the hospital on TPN and. Getting slammed with steroids and other things like that, we don't expect them to go home in a couple of days, but they will go home in 3 or 4 days because by by stopping the inflammation and taking away the narcotics, giving them goal-directed fluid and helping them rehab immediately, they're up walking, they're eating, and they just take a little bit longer, but they do. Uh, change, um, the length of stay and the complication rate. Mark Kurt, I just wonder if you can comment on the relative importance of all these physiologic things we do, whether it's the carbohydrate load before the not NPO and all that stuff versus just the psychological impact of telling the patient what to expect and what the goals of therapy are and saying you can go home when and after these boxes are checked. Because I, I think that that's that second piece I know we have, we have our Katie, our nurse practitioner do that, uh, and Ashley, but I, I think that that is a key component of this that is probably. As I mean, I think it's on equal footing with all those physiologic things that we do. So, uh, um, uh, you're right, right on mark that by giving the patient kind of a timeline, giving them expectations and giving them some control of their care, they, if you inspire them like NewtRockney, they will, they will embrace this and, and they'll push it and, and, uh, as I just described from that galley mentioned a minute ago, um. There are a number of these components that have by themselves their evidence base is not necessarily significant, but when, when Calebundled them like all the other bundles we use by themselves, they're not so significant. When you put them together they make a second order change and so it really makes a big deal. So Matt Kurt, you mentioned a moment ago about the nurses aren't aren't feeding me um. What do you do when you start a program like this with your colleagues and partners who say that's not the way I do it? What do you do with the anesthesiologists who say wait, are you telling me how to do this? And what do you do with the nurses who, as you know, even when we switched to uh after pyloarotomy and we all realized ad lib feeds was fine, if you actually went up on the floor 68, 10 hours later. The nurses weren't feeding those babies, so, um, can, uh, can I answer your slide by showing thank you for asking for my next slide. Um If slides slides back on please. So, uh, this is Steve Jobs when he's a lot more, a lot, a lot thinner. Um, does anyone recognize this, uh, uh, you know, Gordon Gekko has this cell phone in his hand, right? It has a name. It's called the brick. OK, um, the brick is, and when he got out of jail, one of the only things they gave him in the basket in the movie was they gave him the cell phone back 30 years later. So the BRIC to me kind of exemplifies our traditional strategy of communicating with people in surgery with our other colleagues. We live in an environment where we have computers that can search the web and yet sometimes we communicate with our colleagues in a relatively old fashioned way. So I put this extremely contemporary slide on here to say the one thing we learned about the US gymnastics team is these guys are talking to each other and supporting each other all the time. So the last component of the ERAS thing is that we audit our compliance with these things on a monthly basis and so we sit down together with a team. The team is our anesthesia colleagues. Um, we have perioperative nursing care, pre-op, uh, in day surgery. We have floor nursing and we have a nurse clinician that kind of runs the show. Uh, I maybe, uh, uh, I guess I'll show you this slide here. The most important thing that we've done in our institution is to create a team to help address this, and you can see that I've done this for 4 years. In the 1st 3 years I was monitoring these principles heavily myself and communicating one on one with the anesthesiologist, and I managed to get sometimes 5, sometimes 7, sometimes 8. Components done, but once I formally created the team, got a nurse clinician to help me and got the anesthesiologist to own this, the anesthesiologists see this as part of their future. The concept of the surgical home is what the anesthesiologists want to get to, and this is an important part of that. And so. On Monday this week we totally dropped the ball and we miscommunicated and only got half of the components for a patient, but for the most part we have really gotten complied with many of these components and it's really changed dramatically as you can see the length of stay for our IBD patients. This is in our monthly meeting, we are talking at a relatively immature level about compliance. We talk about each individual patient that we've done in the last month and learned from the mistakes we've made. We identify in everyone's presence who's coming up this month and what to expect. We talk about things that need improvement. If you go to YouTube and look up enhanced recovery after surgery, there are 10 or 15 videos. They're all from adult hospitals that have put this in place, and you can just watch them. They take 5 minutes or 10 minutes, and you see what they're doing with a video like Jason did to help get their patients ready. And um I, we need a sugar daddy in Atlanta to help pay for one of these, but uh they're very well done. Many of them have a British accent when you and and uh so they're fun to listen to. um, but anyway, and then we just keep going back to this idea about uh building the team with uh understanding about what this is because what the nursing staff sees in this enhanced recovery thing is very different than what you see. And and also the anesthesiologists, they are experts at what they do, but they don't understand. The MIS component as well as you do, they don't understand kind of the preoperative physiology change that you're inducing here. And so training your team, I think, is very, very important. The Emory adult colorectal system is much more mature and they have a checklist. This is their pre-op clinic checklist. This is their day surgery checklist. This is day of surgery, post-op day 0. This is post-op day 1 and. In addition to the checklist on the chart, they hand the patient their goal sheet, and the patient, as Mark said, understands what's expected of them, so they become your partner rather than someone you're telling what to do or what's going to happen next. Um, so I, I wrote down just a few things here kind of like David concluded his talk. Um, I think it's really important to identify team members and uh it's super important to find a young anesthesiologist who, who engages in this. Last year's Society of Pediatric Anesthesia was all about enhanced recovery, and when they were having their meeting, all the anesthesiologists were texting me. Twittering me from the meeting about the different things that they were talking about, so this is very exciting for them. We just have to figure out. Like Gordon Gekko, how to use a better, a better communication strategy, and one of them is getting your anesthesia colleagues harnessed and being your partners in this. Uh, there's YouTube videos. The ERAS Society has a boatload of stuff we've talked about it as a division, uh, as you pointed out, there are people in your division who are gonna come to this much more slowly than others, and that's just fine, but the, the. Uh, abstract that we sent to the AP that had that graphic on it about how the length of stay had changed as we complied with this, your colleagues are going to respond to data and so I guess I, I went slowly on this because I figured uh if I could provide information and outcomes that were better to my partners that they would embrace it whereas if I just. You know, talked about it and said we all ought to do this, it would have a different outcome. Having engaged nurse clinicians are important. Uh, this Katie Burch really is my alter ego. She helps accomplish a lot of the things that I couldn't do because I'm doing something else. The residents that come from general surgery who are in adult colorectal programs, they understand this. One of my, I went to another hospital recently to invite them to send their IBD patients to us, and I gave them a presentation on enhanced recovery. One of the gastroenterologists said, How many surgeons at your hospital are using us? My response was 11%. And uh and he thought for a minute and then he laughed because he recognized that it meant that this pretty much me so far had done it, but uh this was a while back and my partners have started to embrace this as well. Um. The residents noticed this and uh for the last 6 months my two fellows have surreptitiously been erassing my partner's patients when they weren't looking so there is a. Halo effect that occurs once you have the data and people understand it, so. Uh, since I'm a quality leader in our hospital, I would just say that as you approach the quality leadership in your hospital and talk about this, um, they can help bring resources to help you develop it. Um, they can give you resources to help you measure it. Uh, last week as we met and talked about some of what we'd accomplished so far, I was given the assignment by one of our vice presidents to create. A guideline that was hospital-wide for this that we could put on our website and begin to invite people to comply with. We use quality tools like anything else plan do check act. The cycle of improvement has to occur here because we're going to make a lot of mistakes and. Doctor Raval has has helped me a lot with this, and as we've talked about this, it's very seductive to spread this to other services because urology would really benefit from this in their open cases. The head and neck surgery would benefit from it. Having said that, It's better to underpromise and overdeliver, and many of us have limited resources, so I think it's really important to put this in place in a solid foundation in your own house, in your own division, before you start sending it to other places, at least that's the way we've approached it at this point. All right, we come to the portion in the talk where Morpheus invites us to take the red pill or the blue pill. You remember the blue pill is we go back to our own way of life and forget we ever heard this talk, or we take the red pill, crawl into the rabbit hole, and change the future of surgery. So that's my invitation. Happy to answer any questions. Very good. Can I just, uh, in about I wanna do this in about one minute. I wanna fly through and make sure I'm getting that. Go for it. Patient comes in. What, first of all, let's take an example of an operation because that's what confused me because is it bowel surgery? Is that our would this work for so that the, uh, give me the classic patient that would be good. Well, those were that graphic I showed you was for IBD patients, OK, in case we've used a patient, but, but you know what's happened, Todd, is that there are certain principles of this that I think work for any surgery, for example. Of the gabapentin, so that we've started using Neurontin on, on a lot of our patients for pain control, and you totally eliminate narcotics. So you totally eliminate nausea. All right, so my, so my, my, the appendectomies that I have influence over post-op are just getting, are getting, uh, rest, right? OK. But let's start some pre-op, OK, so patient comes to me. I'm, I'm trying to think of, let's say it's an IVD, OK, they, they have an ileal stricture, and you're gonna do an ile strictectomy. OK, perfect, because I'm having one coming up. So this is what I'm gonna do for her. So she came and saw me. Yesterday actually. So, um, I'm gonna give her, what are HOs I'll give her, gives HO. A handout. Give her a handout, handout that has all the invitations here. Yeah. Give her, give her the, so, so we got to make handouts for her. Then scripts her, but we're not using narcotics anymore. But we're gonna give her a script for GB is a controlled substance. So GB, give her a GABA script. I should be giving a GABA script. Yeah, OK. So I'm gonna give her a handout because they'll come in and you give them an industrial strength dose of gabapentin and Tylenol. Pre-op. I've never prescribed it in my life, so this is going to be so in-house, in-house we use 10 per kilo, but uh if you ask your neurologists, they, they start at that and they keep going up until they get the effect. What's the story with gabapentin? How does it, is it like a, is it doesn't have the side effects of a narcotic? That's right. That's the whole point, a Toradol in the sense that it's not. It's a, it's a, it's an anti-seizure medication, but But it's, uh, what it does is it influences neurologic pain and it really works well. It's, it's, it does if you've ever had narcotics as part of the bundle, it seems to, and, and I can tell you, well, no, but I can tell you that that the patients that are getting gabapentin, it's, it's, it's a very different experience. OK, so I'm gonna give her a script for gabapentin and I'm gonna, uh, give her a drink. What's the, so that you give her a script for gabapentin and you give her your pre-op oral antibiotics at the same time for your colorectal patient. OK, give her flagellin neo, fine, fine, OK, OK, got it, yep. And then she, I'm gonna see her back again in clinic. Uh, I don't routinely do that, but, but in, in adult programs they all go to the pre-op clinic and they're gonna get hit again with all this information and be often given Clear fastest or some other high carbohydrate long acting. You normally have a pre-op clinic. Well, so we have a pre-op clinic for kids that are above ASA 3 and above, right? So if this is a patient who's on steroids and they're a bad IBD patient, they're gonna show up in a pre-op clinic. They've been flagged in EPIC or is in our system as an ERAS patient. And our nurse practitioner will go there, meet them there, and reemphasize all the things you talked about in the protocol. OK, good. So, uh, Steve or Mac or Carlos, I don't know if anyone does this out in South America. Do you guys have a pre-op clinic for certain patients, not the ones that, not the ones that have. Cardiac issues or severe pulmonary, I'm talking about, do you have a thing like this? No, no, that's what this is. This is, this is the anesthesia. We don't see. This is not a surgery clinic. This is the same thing, the same thing that you send somebody, like I said, any patient in our institution, our anesthesiologists want to see every patient pre-op who's ASA 3 or 4. OK. All right, uh, drinks. CHO clears carbohydrate clears. So first of all, what's interesting is Journal of Pediatric Surgery, another plug. This last issue showed that guess what percent of, guess what percent of patients, so we tell our patients, we give them our NPO guidelines, the 24, 68, the thing that's above your desk. Guess what percentage of patients actually, uh, comply with that or, or, or actually come in and. Complied with that. In other words, they, they, they are NPO longer than they should be. What percentage of patients are NPO longer than they should be coming to the operating room? It was just published this last journal. OK, guess, 85, 50%. Would you make, yeah, you say 85%. There's no way I can make it look sound impressive when you say that. So 70%, 70% of patients are NPO longer than they should. They come in dehydrated. OK, so you're going to give them a carbohydrate drink, apple juice, Gatorade, Gatorade, and they take two hours before. Well, they're drinking this stuff on the way to the hospital, on the way to the hospital, and then who does that? Does anyone do that? Who does that? You do that. You give them Gatorade on the way to the hospital. Amazing. Yeah, wow. So Todd, the thing that's, that was such a surprise to me is that the national anesthesia guidelines say that it's OK to drink carbohydrate, clear liquids until 2 hours before the operation. It's always been there. We just haven't used it. Yeah, they're. I mean, because we've been saying NPO after midnight for 100 years, so it's, it's, it's, it's part of the sort of mythology, yeah, as of today, no more, right? I just talk to your anesthesiologist before you do this, OK. OK, pain med cocktail in pre-op. What's your pain med cocktail? It's the Neurontin and Tylenol. If, if across the street they use Celebrex too, they give them so we're really getting away from narcotics. That is interesting because you mentioned the inflammatory response which the COX-2 inhibitor is going to stifle, and you're not using that in your Neurontin, not yet, not yet, sir. What's GDFT again? Goal directed fluid therapy, right? What was the example. So what they will, so traditionally, you know, you drink, you don't swell, yeah, well, but I mean, uh, when, when we talk about the patient after the operation, the anesthesia residents usually with pride say I gave him 4 ccs per kilo per hour, and there are so. They are so proud of what they've done. So who puts Foley's in routinely for an appendectomy? A Foley catheter, urinary catheter. Do you put in a urinary catheter routinely? Never. Who has them pee in pre-op? All their patients for appendectomy. Appendectomy. I haven't. I, all 100% of my patients have to pee in pre-op unless they have something weird. All right, so, um, but what do you do for like a J pouch? I assume you have, we, we put, we put the Foley in and then after the case is done we take it out, OK, and no urinary retention issues. No. So in, in, in a J pouch we'll leave them overnight and take it out in the morning. But, uh, for the most part, um, it with an ileoscectomy it's right afterwards. Steve, do we still need OG tubes before doing laparoscopy, NG or OG to decompress the stomach so you don't hit it on the? Well, that doesn't mean don't. I know. I'm just asking just a random question because we talked about this in the OR yesterday. I still do it. I still decompress the stomach with an OG tube if I'm doing laparoscopy. Is it unnecessary? It's probably unnecessary, but if you ever got, had an injury and got. Right, I mean, if you're taking that splenic flexure, it's really nice to have the stomach out of your way. Well, I, yeah, I mean, the, the other thing, I, I don't do it for the, for necessarily to prevent injury because it's, I, I think it's almost impossible to hit a mobile hollow viscus. I agree with you that, that being said, uh, it, you know, in a little baby, if you're doing a little baby neonatal laparoscopy. They fill up the stomach with this much air, one peristaltic wave, and then you have a bowel full of air and it makes your operation that much harder. Amen. Who's who, but don't leave it post-op. Go ahead, OK, go back to this pathway. So we just looked at our colon SSI pathway bundle, whatever, and looking at the adult literature, it's pretty clear that mechanical bowel prep is a higher leak rate, higher complication rates. It seems to be unclear that oral antibiotic prep without mechanical prep is of any value. No, actually, I think that's, I think I disagree with that. The literature has swayed completely. Yeah, so it changes every year, but the one thing that is consistent is oral antibiotics make a big difference, makes a difference. Adults, so not without mechanical. The most recent literature is adding both together back. Yeah, we're back to where we were before. Don't do mechanical circle. Don't, don't be having a different conversation. So every year, so all of their carbohydrate drink is coming right out through their bottom because you just gave them, but you have to balance it. But you're right, the most recent stuff. Says if you do mechanical and oral it's the best. So, so every year at the Nis quit meeting Patch Dellinger gets up and gives an update and so. And so this year he said exactly what you did. It seems that adding the mechanical bowel prep may provide a benefit, OK, but it's, we're taking this in a cumulative fashion because if you read it a year ago it didn't. And so 9 to 8, it's still for mechanical or antibiotics alone, and next year it's gonna be 99 maybe Max stoma takedown. Do you do anything for them before you do a stoma takedown? Does, does anybody in a does anyone do baby foul pipes? I give, I give oral antibiotics to the kids beforehand, OK. Um, who takes, who lets the parents go back in the room with the patients? Who lets parents back in the room, Parents back in the room, the parents back in the room. So I, this is my biggest pet peeve is that when my previous hospital, they all, they came back. I loved it so much. I'll tell you, if it was my kid, I'm going back with them where I am now, they have published papers to say that they give Versed instead and they think that it's, it's better. And they've dated as well. You're nodding your head. Do you agree? No, no, no, I don't, I don't agree or disagree. I mean, they have data to show that you can talk about the psychological effects on the parents, on the, on the kid. It makes no difference, no difference. I don't think on the kid, it makes a difference. That's gonna be a good study, Sophia and Ian. We're gonna do that. Look at the parent. All right. I, I wanna make sure I got everything. GABA. I'm, so we're gonna start doing GABA. I'm gonna look into that, but I have to give them the script preoperatively and tell anesthesia to do it post-operatively, early ambulation. We got it. Remove the Foley and the NG tube. And you give them stuff to drink right away. So if they drink successfully one time, then we give them something to eat. You give them solid food. So, so this is if you know the Decadron makes them hungry, the Zofran makes the uh the nausea go away, and you haven't over hydrated and you haven't given them narcotics, so their gut's ready to work. And if they can drink successfully, we don't, we don't bring, you know, avalanche pizza in for them, but we let them have solid food and And just tell them to graze and, and you know the one gal had a chicken salad. Other people are just eating yogurt or chips or something like that. But on post-op day one, we want, we tell them your job today, barring they have are having significant problems, your job today is if you have an anastomosis, yeah, anastomosis, you're giving regular food on day one. Yeah, so I mean, Todd. The the when we just staple that thing, drop it back in, it's secreting fluid right away. I know. And and so I know, I know. So what about narcotics? The sooner you feed them, the faster they. No narcotics in. OK. Who feeds their patients regular food on day one after a bowel anastomosis? Me and Carlos say no, no, no, I think, but I think that, but I think what we're doing here is we're debunking. There's a lot of surgical mythology, I know, and, and, you know, it's like sort of like NG tubes. We used to put NG tubes in for ileus. Well, guess what? NG tubes prolong ileus because you're sucking out all that stuff that goes downstream and makes things work. So I didn't, so there's a, there's, I'm sorry to interrupt, but there's one thing that I didn't include in here which, um. You can't give it to little kids, but give chewing gum to the school-aged patients and just tell them your job today is to chew this chewing gum, and they start chewing it. They're generating a boatload of saliva. It's going down their GI tract. Their bowels starting to work, their bags pumping gas out. It's the chewing gum is, is a nice cheap addition. What happens when someone falls off protocol? I'm going to assume that one of your patients, that's an excellent question, so and a residents on at 2 in the morning and what happens? Well, if they fall off the protocol, then we just, I mean. All the papers that Mattei and Yuri showed only had 5 components. I mean, when Gawandi wrote the, the, the checklist manifesto, they had a 30% compliance rate with that protocol and it dropped the mortality in half. So if they, if they missed a few buttons, we, we talk about it in the audit. Committee or in the monthly meeting, but we press on. Jason, yeah, yeah, so the patient, so, so again, if the patient, if the patient, if the patient doesn't tolerate the liquids or they start to throw up, so you stop feeding them. Yeah, yeah. So it's, it's very simple. So I, I thought you were, what I thought you were gonna ask me is what happens when they have patient's not listening, what happens when they have, what happens when they have a complication. If they have a complication, they have a bowel obstruction, they come off the ERA protocol. You treat them like a traditional patient. So what percentage come off in that fashion? Well, ours, our data is 10%. 10%, but our, our numbers when we wrote that article, the numbers were pretty small. So we, we've had in the last year we've had a leak, um, first leak in a few years we've had, uh, we've had a bowel obstruction and so as, as you chewing gum, wasn't chew the nice thing about the staple anastomos. This is 6 centimeters long. You can get the chewing gum through. Yeah, but you know what I'll say, yeah, so when Kurt started talking to me about this and, and Sage just published a bariatric protocol and my sleeve gastrectomies were going home in 1 or 2 days, and I used to always say 1 or 2 days in my head it was 1 day, but it was really closer to 2 days on average when I'd send them home. And I'm like, well, why should I even bother to do this because I'm saving one day. It didn't seem like it seemed like a long run for a short slide. So this year we started to implement this and I mean again a very small numbers, but so far every patient but one has gone home on post-op day one. And it just and the patients are coming out with a lot less pain and they seem to be doing a lot better. The main difference between what we were doing before and what we're doing now, because we did, I mean, I do a sleeve gastrectomy. It's the longest staple line in surgery, right? And we were still giving them liquid. They only get liquids for a while, but we were feeding them the first day before anyhow, and we have yet to, you know, we haven't implemented the pre-op carbohydrate yet because we've been telling them for 6 months you can't have sugary. Drinks. So, so I haven't been able to convince the pediatrician to do that yet. But, uh, at the end of the day though, just adding a few of these components, I think to Kurt's point, you know, with compliance and stuff, you add a few. I, I think in, in that patient population, the GABA totally changed the deal. But, so, uh, Doctor von Almen, I'm gonna have to communicate with you through telepathy because I can't see you. So, um, do you have an ERAS program? That's my first question. It's a multi-part question. Do you have an ES program? Uh, we do not have, we do not have this as a formal, uh, program yet, but as Jason, uh, alluded to, we are considering, uh, implementing that as part of a study. OK, so here's my question for you. You just did a laparoscopic duo, uh, duodenal atresia repair and a baby. You're gonna start feeding the baby that day? No, OK. Who, Steve, would you feed the Did the lap duodenal and treasure repair that day? That's a different. Oh, why? Because a patient with neon Atonic and atonic stomachic. OK. If I do an ileostomy takedown or if I do a laparoscopic resection for an ileal stricture for Crohn's disease, the answer is yes, I would feed them. I put them on clears advanced to regular is tolerated. Dan, do you send your appendectomies home from recovery? Not from recovery, but we send them home same day because frequently they're inpatients, so they go back to the floor and if as long as they drink, they go home. OK, um, Mac, do you do, you said you do ad lib feeds for pyloyotomy? Yes, OK. I'm just trying to see all these things are, are, are rapidly changing, and I wanna see, you know, it seems like, uh, you know, I get really frustrated with these because I, no matter how many of these I do, I'm the only one in the room that seems so outdated every single time we, well, Todd, I think you've organized this whole thing just for your own continuing education. That's why I do it. Any other, um, issues that weren't addressed because I think this was a great way to end it because I, I have to be honest, I think this is spectacular. And I think it's something that you'll come, we'll come back next year and you'll see that this will probably be the biggest change you'll see people getting involved with this. So the thing that I did that was so impressive is, uh, he, he used this again. He used 5 components and he, he went through this in a couple of different iterations, but the one thing that he, that he talked about in each of the papers is the parents loved it. The parents loved it because they were giving some influence over the care of their child and the kid wasn't starving all the time and so it's a big deal. Well, I wanna thank, thank.