Table 7.
Standard ERPs vs. SDD for MIS CRS
| Standard ERPs for elective colorectal surgery | SDD for elective colorectal surgery |
|---|---|
| Surgery consultation and preparation phase | |
| Patient and family/social support education | Extensive patient and family/social support education |
| • Setting up expectations for early ambulation, multi-modal pain management, hospital length of stay | • Setting up expectations for early ambulation, multi-modal pain management, hospital length of stay |
| • Social support at home | |
| • Distance from hospital assessment | |
| • Plan ahead/worst case scenario: don’t delay, and return to same hospital/emergency department as surgery location if problems or complications arise | |
| • Set up remote monitoring plan (phone, video, or app remote monitoring) | |
| • Provide contact information for Surgical Department, Hospital, etc. for urgent questions or issues | |
| Preoperative optimization & pre-habilitation | Preoperative optimization |
| • Weight loss (Ideal BMI 30) if possible | • Weight loss (Ideal BMI 30) if possible |
| • Exercise/conditioning 20 min daily sustained activity (in ambulatory patients) | • Exercise/conditioning 20 min daily sustained activity (in ambulatory patients) |
| Preoperative nutritional assessment | Preoperative nutritional assessment |
| • Alternatives to anastomosis planning for sub-optimal nutrition levels | • If low nutritional levels, not an ideal candidate for SDD ERAS (Alb < 3.5 or Pre-albumin < 21) |
| • If NEW ostomy (temporary or permanent needed), not an ideal candidate for SDD ERAS | |
| Management of anemia | Management of anemia |
| • Alternatives to anastomosis planning for sub-optimal Hgb/Hct levels vs. pre-operative correction of anemia (IV Iron, pRBC Transfusion, etc.) |
• Anemia is a contra-indication for SDD Note: If low Hgb/Hct (< 10/ < 30), this is a contra-indication for SDD |
| Day prior to surgery preparations | |
| ± Bowel preparation | ± Bowel preparation |
| Electrolyte therapy/hydration | Electrolyte therapy/hydration |
| Decreased fasting | Decreased fasting |
| Antimicrobial prophylaxis and skin preparation | Antimicrobial prophylaxis and skin preparation |
| Dietary supplementation (Immunotherapy drinks) | Dietary supplementation (Immunotherapy drinks) |
| Day of surgery preparations and pre-op anesthesia | |
| Dietary supplementation (Immunotherapy drinks) | Dietary supplementation (Immunotherapy drinks) |
| Decreased fasting | Decreased fasting |
| Pre-operative warming | Pre-operative warming |
| Maintain normal glycemic levels | Maintain normal glycemic levels |
| Thromboprophylaxis | Thromboprophylaxis |
| ± Alvimopan | ± Alvimopan |
| Pre-operative patient/family/support re-education | |
| • Early ambulation after surgery (sitting in chair, then walking) | |
| • Multi-modal analgesia plan | |
| • Patient check In–solicit their intent to proceed with SDD vs. standard of care post operative hospitalization | |
| Intra-operative care | |
| Minimize intra-operative fluids/hemodynamic goal directed therapy | Minimize intra-operative fluids/hemodynamic goal directed therapy |
| • 500–700 mL maximal IVF goal | |
| • Approximately 3 mL/kg/h for an average 70 kg patient | |
| Surgical approach | Surgical approach |
| • Minimally invasive surgery | • Minimally invasive surgery |
| • Less painful specimen extraction site: natural orifice, pfannenstiel | |
| • Intra-corporeal anastomosis | |
| Avoid nasogastric tubes and unnecessary drains | Avoid nasogastric tubes and unnecessary drains |
| Prevent intraoperative hypothermia | Prevent intraoperative hypothermia |
| Maintain normal glycemic levels | Maintain normal glycemic levels |
| Analgesia/anesthesia | Analgesia/anesthesia |
| • Multimodal anesthesia | • Multimodal anesthesia |
| • Narcotic sparing approach | • Narcotic sparing approach |
| • ± Epidural–only recommended in open cases | • Abdominal wall blocks (TAP/rectus sheath) |
| • ± Spinal anesthesia for MIS cases | • Propofol, lidocaine, dexmedotomidine, ketamine hydrochloride infusions |
| • Abdominal wall blocks (TAP/Rectus Sheath) | • Bispectral index (BIS™) monitoring |
| • ± Posteromedial quadratus lumborum (QL) block Note: Epidural/spinal blocks not recommended for SDD programs at this time due to potential for urinary retention, vasovagal responses, and need for hospital monitoring | |
| Post-operative recovery phase | |
| Postoperative fluid and electrolyte therapy (avoid over resuscitation) | Postoperative fluid and electrolyte therapy (avoid over resuscitation) |
| Prevention of postoperative ileus | Prevention of postoperative ileus |
| • Limited opioid use/focus on short acting opioids | • Limited opioid use/focus on short acting opioids |
| • Multimodal analgesia therapy | • Multimodal analgesia therapy |
| • Avoiding routine NGT | • Avoiding routine NGT |
| • Maintaining fluid balance | • Maintaining fluid balance |
| • Alviompan (if given pre-op) | • Alvimopan (2nd and last dose; if given pre-op) |
| • ± Chewing gum, magnesium oxide | |
| • Early out of bed to chair (within 1 h of PACU arrival) | |
| Post-operative glycemic control | Post-operative glycemic control |
| Post-operative nutritional care | Post-operative nutritional care |
| • Offer clear liquids immediately (typically does not occur until Med/Surg hospital admission) | • Offer electrolyte clear liquids immediately In PACU (once sitting in chair) |
| Post-operative ambulation | Post-operative mobilization and ambulation |
| • Encourage early ambulation | • Early out of bed to chair (within 1 h of PACU arrival) |
| • Ambulation once full level of alertness achieved | |
| • ± Visit with physical therapist in PACU per hospital/PACU staffing and availability | |
| Post-operative deep breath teaching | Post-operative deep breath teaching |
| • Incentive spirometer education In PACU | |
| Urinary drainage | Urinary drainage |
| • Foley removal POD 0–1 in colon surgery |
• Avoid routine foley in colon surgery or anterior resection Note: LAR/APR patients with diverting loop ileostomy are not considered candidates for SDD ERAS (ostomy teaching/high output ileostomy management and prevention, etc.) |
| • Foley removal POD 2–3 in rectal surgery | |
| Discharge criteria | |
| Full recovery from anesthesia | Full recovery from anesthesia |
| Tolerating liquids or solids without nausea or vomiting | Tolerating liquids without nausea or vomiting |
| • I-FEED score: 0–1 | |
| • Early/immediate anesthesia emergence nausea and vomiting with resolution is acceptable, so long as I-FEED score is 0–1 prior to discharge | |
| Absence of clinical findings suspicious for infection or bleeding | n/a |
| ± Flatus/BM | n/a |
| Voiding independently | Voiding independently |
| Discharge instructions | Discharge instructions |
| Wound care, diet, after hours contact information, regular business office hours contact information, post operative visit(s) scheduled, pain management reviewed, when to call/what to be concerned about during recovery | Wound care, diet, after hours contact information, regular business office hours contact information, post operative visit(s) scheduled, pain management reviewed, when to call/what to be concerned about during recovery |
| • Review and confirm social support at home | |
| • Distance from hospital re-assessment | |
| • Worst case scenario action plans: don’t delay, and return to same hospital/emergency department as surgery location if problems or complications arise | |
| Review and confirm remote monitoring plan is in place (phone, video, or app remote monitoring) | |