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Enhanced Recovery After Surgery (eRAS) is a multidisciplinary approach to improve patient care using a combination of evidence-based methods. the interventions found in eRAS protocols are based on the rationale that patient outcomes can be improved by controlling pain and optimizing fluid administration, early ambulation, and nutrition to prevent catabolism and immune dysfunction. there are Enhanced Recovery after Surgery (ERAS) protocols have revolutionized the care of surgical patients, contributing to shortened hospital stays and reduced narcotic use amidst a national opioid crisis. 1 An ERAS pathway includes a standard perioperative pain medication regimen combined with strategies to enhance postoperative recovery to allow a rapid return to function and reduced hospital stay. ERAS/SSI patient 1. Selected patient placed on ERAS/SSI pathway 2. Flag placed in Epic that will be visible whenever Epic opened during episode of care that makes it clear to all providers that patient is on ERAS/SSI pathway Assessed by: 1. Appropriate demarcation and verification of Patient’s ERAS/SSI designation Documented in: • Patients should receive gabapentin 300mg prior to surgery unless patient is already taking gabapentin and already took gabapentin at home. • Patients should receive 400mg of celecoxib orally prior to surgery except for patients To minimize opioid demands, ERAS uses adjunct medications and a multi-modal approach. Acetaminophen (Tylenol), gabapentin (Neurontin), celecoxib (Celebrex) and regional nerve blocks have been found to synergistically reduce postoperative pain and thus opioid needs. Some protocol recommendations are quite prescriptive and include dosages and timing of administration, while others are more general and will require discussion among the ERAS® team prior to implemen-tation. In rare instances, no standard of care exists and more than one option is provided. 1.1. Preoperative interventions. We defined perioperative gabapentin use based on charge codes, which identify each service item (eg, medications and procedures) for billing and reimbursement purposes, on the day of surgery or postoperative day 1 or 2. We calculated total daily gabapentin dose (in milligrams) given during the exposure-defining period. This study represents our early experience. A shift in the institutional mindset of pain control was necessary for adoption of the ERAS protocol. While the ERAS pathway functions to reduce stress and return patients to homeostasis following surgery, postoperative gabapentin resulted in the greatest Gabapentin can be removed from plasma by hemodialysis Bioavailability is not proportional to dose (i.e. bioavailability of gabapentin ≅ 60% (900mg), 47% (1200mg), 34% (2400mg), 33% (2600mg), and 27% (4800mg) per day, given in 3 divided doses. Prescription Post‐operative celecoxib 400 mg initial dose followed by 200 mg bid for 5 days is recommended in patients having a colorectal resection where NO anastomosis is performed (for example, abdominal perineal resection) and where no contraindications to its use are present. A randomized controlled trial (RCT) of 60 patients undergoing abdominal hysterectomy demonstrated a substantial decrease in postoperative tramadol use in patients who received a single 1,200 mg dose of gabapentin preoperatively. The dose of gabapentin is adjusted for elderly patients. Alternative agents include celecoxib 400 mg by mouth and ketorolac, depending on surgeon preference and patient renal function. Our institution does not routinely administer preoperative anxiolytic medications due to unpredictable effects on postoperative recovery and sedation. Most studies used doses of 600 mg to 1200 mg preoperatively in addition to continued administration in the postoperative period. A study of laparoscopic cholecystectomy included in the analysis used a dose of 300 mg. They found that gabapentin resulted in a 35% reduction in total analgesic consumption in the first 24 hours following surgery. We would like to show you a description here but the site won’t allow us. Postoperative analgesic medications may include acetaminophen and gabapentin, as well as the following, as needed: oxycodone, codeine, and hydromorphone or morphine; doses are provided in Table 2. Postoperative antinauseants may include, as needed, ondansetron, dimenhydrinate, and metoclopramide. What is ERAS? ERAS is a . multimodal perioperative care pathway . designed to achieve early recovery for patients undergoing surgery and reduce post-op pain medication usage. ERAS represents a paradigm shift in perioperative care in two ways. First, it re-examines traditional practices, replacing them with . evidence-based best practices . when The four main components of ERAS are: Multi-modal pain control Deep breathing exercises Early ambulation (walking) and Early nutrition These four components will be continuously addressed before, during and after your surgery. A more detailed explanation of the ERAS program is detailed in the following pages. 11/6/18 (WEB) 1 In all six of the other studies [10, 11, 13–15, 19] that investigated gabapentin as a single preoperative dose for PONV, a lower dose of gabapentin was given (highest dose, 15 mg/kg) and all but one of these found no impact on PONV. 3.4. Perioperative Use of Gabapentinoids in ERAS Protocols Preemptive medication strategies (eg, medications given to the patient before surgery), including paracetamol and acetaminophen, gabapentin, nonsteroidal antiinflammatory drugs, and COX-2 inhibitors, have been shown to decrease total narcotic requirements and improve postoperative pain and satisfaction scores in women undergoing total abdominal • Low dose vasopressors restore colonic perfusion if normovolemic • Balanced solutions rather than 0.9NS due to hyperchloremic metabolic acidosis • Maintenance 1.5-2ml/kg/h
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