Perioperative Care in Elective Colorectal Surgery Clinical Practice Guidelines (2018)

Enhanced Recovery After Surgery (ERAS) Society

Reviewed and summarized by Medscape editors

December 03, 2018

The guidelines on perioperative care in elective colorectal surgery were released on November 13, 2018, by the Enhanced Recovery After Surgery (ERAS) Society.[1]

Preadmission Recommendations

Patients should routinely receive dedicated preoperative counseling.

Smoking should cease preoperatively for ≥4 weeks to reduce respiratory and wound-healing complications; shorter periods may still yield lesser benefits. Evidence for a beneficial effect of alcohol cessation on outcomes is limited.

Prehabilitation may be helpful in recovering functional capacity and reducing complications. Less fit patients may benefit more.

Preoperative routine nutritional assessment should be offered. Patients at risk for malnutrition should receive nutritional treatment (preferably orally) for at least 7-10 days.

Attempts should be made to correct anemia (if present) before surgery. Newer intravenous (IV) iron preparations are safer and more effective than oral iron preparations. Blood transfusion should be avoided if possible.

Preoperative Recommendations

A multimodal approach to prophylaxis of postoperative nausea and vomiting (PONV) should be considered in all patients. Patients with one or two risk factors should receive two first-line antiemetics; those with more than two should receive two or three antiemetics. If nausea or vomiting occurs despite prophylaxis, multimodal salvage therapy using drug classes other than those used for prophylaxis is warranted.

Preoperative pharmacologic anxiolysis with long- or short-acting sedatives (especially benzodiazepines and especially in the elderly) should be avoided if possible. Opioid-sparing multimodal reanesthetic medication (dose-adjusted by age and renal function) can be used, including a combination of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentinoids (preferably limited to a single lowest dose).

IV antibiotic prophylaxis should be given to all patients ≤ 60 minutes before incision in a single dose. In addition, oral antibiotics should be given to patients receiving oral mechanical bowel preparation (MBP). Skin disinfection should be performed.

MBP alone with systemic antibiotic prophylaxis should not be routinely used for colonic surgery but may be used for rectal surgery. Some evidence supports the use of MBP plus oral antibiotics over MBP alone.

Patients should be as close to euvolemic as possible when they reach the anesthetic room, with any preoperative fluid and electrolyte excesses or deficits corrected.

Patients may consume food up until 6 hours and clear fluids up until 2 hours before initiation of anesthesia. Patients with delayed gastric emptying and emergency patients should fast overnight or stop consumption 6 hours before surgery.

Intraoperative Recommendations

Short-acting anesthetics, cerebral monitoring, neuromuscular monitoring, and complete reversal of neuromuscular block are recommended.

Fluid excess leading to perioperative weight gain >2.5 kg should be avoided. A perioperative near-zero fluid balance approach should be preferred. Goal-directed fluid therapy (GDFT) should be adopted, especially in high-risk patients and patients undergoing surgery with large intravascular fluid loss. Inotropes should be considered in patients with poor contractility.

Reliable temperature monitoring should be undertaken in all patients. Active warming methods to prevent inadvertent perioperative hypothermia (IPH) should be employed.

A minimally invasive approach is advantageous for enhancing recovery and reducing complications, as well as facilitating administration of many components of ERAS.

Pelvic and peritoneal drains should not be used routinely.

Postoperative Recommendations

Nasogastric (NG) tubes should not be routinely used after surgery; if inserted intraoperatively, they should be removed before reversal of anesthesia.

Opioids should be avoided to the extent possible. Multimodal analgesia should be used in combination with spinal/epidural analgesia or transversus abdominis plane (TAP) blocks when indicated.

Thoracic epidural anesthesia (TEA) with low-dose local anesthetic and opioid is recommended for open colorectal surgery. For laparoscopic surgery, TEA can be used but cannot be recommended over several alternatives.

Spinal anesthesia with low-dose opioids is recommended as an adjunct to general anesthesia in laparoscopic surgery.

Lidocaine infusion can reduce opiate consumption but has not been clearly shown to reduce postoperative ileus.

TAP blocks may reduce opioid consumption and improve recovery. Ultrasound-guided and laparoscopic approaches have been described.

After a major procedure, patients should receive (a) mechanical thromboprophylaxis with compression stockings and/or intermittent pneumatic compression until discharge and (b) pharmacologic prophylaxis with low-molecular-weight heparin (LMWH) once daily for 28 days.

Net "near-zero" fluid and electrolyte balance should be maintained. For pure maintenance, hypotonic crystalloids are preferable to isotonic crystalloids. For loss replacement, balanced solutions are preferable to saline 0.9% and saline-based solutions. Arterial hypotension in patients receiving epidural analgesia should be treated with vasopressors after normovolemia is ensured.

Routine transurethral catheterization is recommended for 1-3 days after surgery, with the exact duration individualized on the basis of known risk factors for retention. In low-risk patients, the catheter should be routinely removed on postoperative day 1; in moderate- or high-risk patients, catheterization is required for up to 3 days.

A multimodal approach to minimize postoperative ileus should be followed, including limitation of opioids, use of minimally invasive surgical techniques (when feasible), elimination of routine NG intubation, and GDFT.

Hyperglycemia should be avoided. Several interventions in the ERAS protocol prevent insulin resistance and thereby improve glycemic control without causing hypoglycemia. For inpatients, insulin should be used judiciously to maintain blood glucose as low as feasible.

Most patients can and should be offered food and oral nutritional supplements from the day of surgery. Malnourished patients benefit from perioperative immunonutrition.

Early mobilization should be encouraged.

For more information, please go to Colon Resection, Total Mesorectal Excision, Laparoscopic Left Colectomy (Left Hemicolectomy), Laparoscopic Right Colectomy (Right Hemicolectomy), Open Left Colectomy (Left Hemicolectomy), and Open Right Colectomy (Right Hemicolectomy).

For more Clinical Practice Guidelines, please go to Guidelines.

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