DEBATE?

1. DEBATE?

2. THERE IS NO DEBATE

3. Traditional Perioperative Care • Starve • Stress • Drown

4. Enhanced recovery after surgery Surgery Multi-modal intervention Functional capacity Traditional care Days Weeks

5. Surgery ↨ Anesthesia Ward C L I N I C HDU KCH Fearon 2004 PATIENT’S JOURNEY Home Preop Audit of compliance & outcomes

6. Core Protocol Preadmission counselling Audit of compliance/ outcomes Selective bowel-prep Perioperative oral nutrition CHO- loading/no fasting No - premed Early removal of catheters/drains No NG tubes ERAS Thoracic epidural Anaesthesia Stimulation of gut mobility Short-acting Anaesthetic agent Prevention of nausea and vomiting Non-opial oral Analgetics/NSA ID`s Avoidance of Sodium/fluid overload Standard mobilisation Short incisions Warm air body heating in theatre

7. FLUIDSFOOD

8. RESUSCITATION ELECTIVE SURGERY WET IS BEST BALANCED IS BETTER

9. KCH Fearon 2004 Post-op Weight GainFollowing Colorectal Resection 3-6kg Lobo et al, Lancet Brandstrup et al, 2002; 359: 1812-18 Annals Surg 2003; 238: 641-8

10. Hypothesis Fluid/Saline Overload Hypoalbuminaemia/Acidosis/Hyperchloraemia Gut oedema/Malfunction Delayed recovery

11. Effect of salt and water balance in recovery of gastrointestinal function after elective colonic resection 20 colonic resection patients 10 10 Standard IV Restricted IV* fluids fluids (* 2l H20 and 77mmol NaCl) Lobo et al, 2002 Lancet; 359: 1812-8

12. Standard Group 40 5 Restricted Group 4   p=0.01 p<0.0001 3  35   2 Standard Group  Serum albumin (g/L) Change in weight (kg) Restricted Group 1 30  0   -1   -2 25 Preop 0 1 2 3 4 5 1 2 3 4 5 6 Postoperative days Postoperative days Effect of fluid and salt restriction in post-op recovery

13. 200 150 100 50 0 n=10 n=10 p=0.017 Liquid phase gsric emptying time T50 (min) Standard Restricted Group Group Effect of fluid and salt restriction in post-op recovery 250 200 150 100 50 0 n=10 n=10 p=0.028 Solid phase gastric emptying time T50 (mm) Standard Restricted Group Group

14. Post-op Fluid Management TRADITIONAL OPERATION POST-OP 4-6L 2-4d 2-3L 1-2d 2-3L BALANCED 1-2L

15. What is the evidence base to suggest that BALANCED fluid management can improve outcomes?

16. Effects of IV fluid restriction on post-op complications 172 Colorectal resection patients 86 86 Standard IV Restricted IV fluids fluids 72 69 competed completed Brandstrup et al, 2003; 238: 641-8

17. Number of Patients with Complications (Per-Protocol Analysis) Blinded Assessment

18. Effect of Intra-operative Fluid Management on Outcome after Intra-abdominal Surgery Randomised n=152 Nisanerich et al 2005, Anaesthesiology; 103: 25-32 n=75 n=77 Liberal regimen (Bolus 10ml/kg followed By 12ml/kg/hr) Restricted regimen (4ml/kg/hr) P Intra-op 3.8 ± 1.2 L 1.4 ± 1.0 L <0.001 Day 1 2.0 ± 0.5 L 2.2 ± 0.5 L N.S. Day 2 2.0 ± 0.5 L 2.1 ± 0.5 L N.S. 1.9 ± 0.5 L 2.0 ± 0.5 L Day 3 N.S.

19. Effect of Intra-operative Fluid Management on Outcome after Intra-abdominal Surgery Nisanevich et al 2005, Anaesthesiology; 103: 25-32

20. If you Limit Intra-operative Fluids (10ml/kg/hr), does Early Discontinuation of IV Fluids Influence Outcome? Makay et al (sumbitted) Colorectal n=80 n=41 n=39 STANDARD LIMITED 3L H20/d 154mmol Na/d 3d 2L H20/d 60mmol Na/d 1d

21. Effect of Restricted Intra-op Fluids Plus Discontinuation of IV Fluids on Day 1 Makay et al (submitted)

22. BALANCEDISBEST

24. Postoperative early enteral nutrition Lewis BMJ 2001

25. Traditional Care Day1 ERAS Day1

26. Effect of ERAS on spontaneous oral diet  traditional care  enhanced-recovery protocol Nygren Clin Nutr 2003

27. Complications, length of stay and readmissions within 30 days of colorectal resection * Nygren et al Clin Nut 2005;24:455-461 ERAS GROUP

29. THE END