Anyone who has experienced surgery knows that the first day or two following the procedure can be a roller coaster. Pain and nausea levels can fluctuate. Eating is often a dicey proposition, and the first trip out of bed can be daunting.
UC Irvine Health caregivers, however, are at the forefront of an emerging national trend to change the way patients come through surgery. The goal is to make recovery easier, quicker, safer and more predictable by following a list of evidence-based measures, called Enhanced Recovery After Surgery (ERAS).
“Under this protocol, patients typically feel better, go home sooner and their quality of life is improved,” says Dr. Joseph Carmichael, a UC Irvine Health colorectal surgeon with the H.H. Chao Comprehensive Digestive Disease Center and a national authority on ERAS. “We can achieve this through some fairly simple practices.”
The protocol includes more than a dozen strategies that have been proven through medical research to improve safety and enhance recovery.
ERAS starts before surgery
The process begins before surgery, Carmichael says. Patients are encouraged to remain active or to even get more exercise prior to surgery to build up strength and stamina. Oral antibiotics are prescribed to reduce the chances of surgical wound infection. If colorectal surgery may result in the need for an ostomy bag, patient education begins prior to surgery, rather than after the ostomy is placed.
“Many studies show if you empower patients with information early, and keep educating them, they will have a much greater quality of life after surgery and will feel much less lost in the process,” Carmichael says.
On the day of surgery, patients receive anti-nausea drugs and their first dose of pain medication before those side effects set in. This preemptive strategy has been shown to significantly curtail pain and nausea.
Patients also find lots of changes once they wake up from surgery. Food is offered right away to prompt the intestines to wake up and function, and the IV is turned off as quickly as possible, which limits swelling in the intestines. Pain medications are given on a schedule, rather than “as needed.”
“When you start to do these simple things, you walk in their room the day after surgery and they are sitting up in a chair, looking great and asking when they’re going to go home,” Carmichael says.
Everyone — surgeons, anesthesiologists, specialty physicians, nurses, therapists and dietitians — need to be on board to make the protocol succeed, he notes.
Publishing the new protocol
Carmichael is the lead author of a seminal paper on ERAS that will be jointly published later this year by American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. The guidelines will help hospitals around the country and in Canada adopt the ERAS protocol.
Colorectal surgery patients benefit greatly from the protocol because surgical complications are more common in colorectal surgery compared to other types. However, experts in gynecology, cardiology, hepatic medicine and other fields are looking at adopting the ERAS protocol as well, he says.
Research also shows the protocol can dramatically lower healthcare costs by reducing complications and shortening hospital stays.
“We tend to do things a certain way just because that is how we were taught,” Carmichael says. “ERAS is about destroying dogma. But it takes the whole team.”