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Colorectal surgery has entered the era of minimally invasive surgery, ERAS allows patients with fewer complications and more comfort.
The theory of Rapid Rehabilitation Surgery (ERAS) was first proposed by Danish surgeon Kehlet in 2001.
This perioperative multi-mode optimization plan can achieve the goal of reducing complications, reducing postoperative pain, shortening the length of hospitalization and reducing costs through a series of preoperative, intraoperative and postoperative measures, and returning to normal life as soon as possible.
In 2005, the first ERAS consensus on colorectal surgery was released, and the process of minimally invasive colorectal surgery has developed more rapidly.
In 2018, the ERAS Association updated the ERAS Consensus on Colorectal Surgery and published the fourth edition of the "Perioperative ERAS Guidelines for Elective Colorectal Surgery" (hereinafter referred to as the guidelines).
This edition of the guidelines summarizes and systematically reviews and systematically review evidence-based medicine evidence such as meta-analysis, randomized controlled trials, and prospective cohort trials related to colorectal rapid rehabilitation surgery published between January 2012 and October 2017.
The recommended classification has brought the latest clinical practice basis to colorectal surgeons.
Today we will take stock of updates to the fourth edition of the guide.
1 Before admission: Patient education makes you less anxious and understands more.
The guidelines recommend that patients receive patient education before admission.
The purpose is to let patients have a complete understanding of surgery, so as to reduce anesthesia and surgery-related anxiety and correctly understand surgery-related pain.
In addition, patient education can increase the patient's sense of participation throughout the treatment process, thereby obtaining psychological support.
In addition to the details of the operation and the instructions for hospitalization, the requirements for quitting smoking and drinking should also be communicated in this procedure.
2 Before surgery: Pay attention to prevent nausea and vomiting.
The quality of evidence is stronger than before.
Surgery is undoubtedly a stressful event for patients.
Therefore, the focus of preoperative work is to reduce the impact of surgery on the normal physiological state of patients through all aspects of preparation.
influences.
Because preoperative malnutrition increases the morbidity and mortality of postoperative complications, it is also related to the poor prognosis of cancer patients.
Therefore, positive assessment of the patient's preoperative nutritional status and timely correction will help to achieve rapid recovery.
At present, it is recognized by the academic community that the NRS 2002 score is used to evaluate the objective nutritional risk of patients, and subjective scoring tools such as SGA, PGSGA and MUST are added to improve the nutritional risk assessment.
In addition, two large clinical studies believe that the preoperative plasma albumin level is also related to the patient’s Mortality and mortality are related, so it is also recommended to check the patient's plasma albumin level before surgery and actively correct hypoalbuminemia.
In addition, anemia is very common in patients with malignant tumors, and it is also an important factor leading to surgical complications, death and poor prognosis.
Therefore, anemia should be actively corrected before surgery, try to improve the hemoglobin concentration in a relatively short period of time by intravenous infusion of a new type of iron, and avoid blood transfusion if not necessary.
In terms of preoperative anesthesia, considering that the widespread anxiety of patients may lead to an increase in the need for intraoperative sedatives and postoperative complications, it is necessary to give patients preoperative benzodiazepines to reduce anxiety.
At the same time, adequate communication before surgery and the company of family members can also alleviate the patient's anxiety.
In terms of drug selection, because elderly patients take benzodiazepines, there is a certain cognitive risk.
Therefore, if the patient has serious anxiety and has to take medication, it is recommended to use short-acting drugs to avoid adverse effects on the neuropsychiatric of elderly patients.
.
There is evidence that melatonin also has a good anti-anxiety effect with fewer side effects, so it is recommended for clinical use.
In this guide, the preoperative preparation plan to prevent nausea and vomiting (PONV) has changed from the recommended level in 2012, from low to high.
Severe PONV can cause dehydration, delay nutritional intake, increase the possibility of gastric tube placement, and indirectly prolong hospital stay and increase medical costs.
Therefore, patients with risk factors who are about to undergo colorectal surgery should choose dual or triple combination drugs according to the number of risk factors.
When the patient has nausea and vomiting, remedial medication should be used on the basis of preventive medication.
In addition to the preoperative requirements mentioned above, avoiding mechanical bowel cleansing, preoperative preventive use of antibiotics, correcting water and electrolyte disorders, and giving non-alcoholic carbohydrate beverages 2 hours before surgery are also recommended in the guidelines.
3 During operation: In the era of minimally invasive surgery, deep muscle relaxation and low pneumoperitoneum pressure are more in line with the ERAS concept.
The fourth edition of the guidelines emphasized the development trend of minimally invasive colorectal surgery at the beginning.
In fact, in many countries, minimally invasive colorectal resection (MIS) has replaced the traditional open surgery and has become the standard treatment.
MIS is not only less traumatic, but also has a lower incidence of trauma-related complications (such as incisional hernia and intestinal adhesions caused by surgery).
The patient's body fluids are also less traumatized to avoid unnecessary loss.
In addition, the postoperative pain score of MIS is lower than that of open surgery, which minimizes the use of opioid analgesics and allows patients to recover faster gastrointestinal function after surgery.
The most direct difference between minimally invasive surgery and open surgery is the difference in the surgical field.
In the past, surgical operations often required an increase in pneumoperitoneum pressure to meet the exposure of the surgical field under the conditions of minimally invasive surgery.
Although this method can meet the needs of free surgical operation, high pneumoperitoneal pressure will increase the circulatory burden, hinder ventilation and reduce the blood flow of important organs in the abdominal cavity (such as the kidney).
This method is not beneficial to the patient in the long run.
The short-term prognosis is also a hidden danger to the occurrence of postoperative pulmonary complications.
The fourth edition of the guidelines proposes anesthesia strategies to achieve deep muscle relaxation during surgery and strengthen neuromuscular testing.
There is evidence that deep muscle relaxation can meet the win-win situation of low pneumoperitoneum pressure and satisfactory operation space: because the patient is in a state of deep muscle relaxation, the resistance of the muscles against the pneumoperitoneum is greatly reduced, and satisfactory exposure can be achieved under the state of low pneumoperitoneum.
On the one hand, reducing the intra-abdominal pressure below 10-12mmHg can reduce the impact of pneumoperitoneum on circulation and breathing, minimize aortic afterload, maintain renal blood flow, and reduce the peak pressure of the ventilator. In the past, because anesthesiologists were concerned about the unavoidable residual muscle relaxation in the application of deep muscle relaxation, the application and promotion of deep muscle relaxation was relatively limited.
However, with the popularization of Sodium Gluconate in clinical applications, the residual concerns of muscle relaxation have been resolved.
Sodium sugammadex can accurately antagonize and reverse the muscle relaxation effects of rocuronium and vecuronium, significantly reduce the risk of residual muscle retention, and does not bring the anticholinergic side effects of the traditional drug neostigmine, avoiding The influence of autonomic nerves and heart rate.
In addition, in order to minimize the occurrence of postoperative pain in patients, the guidelines also recommend that the anesthesiology department adopt multi-modal analgesia.
Use general anesthesia or combined epidural anesthesia as much as possible to meet surgical requirements and antagonize the stress response caused by trauma.
In terms of medication, the guidelines suggest that short-acting sedatives, short-acting opioid analgesics and muscle relaxants should be the first choice for general anesthesia, such as propofol, remifentanil, sufentanil, etc.
, muscle relaxants can be considered Curonium, cis-atracurium, etc.
4 Postoperative: Pay attention to postoperative pain management and accelerate the recovery of intestinal function.
After the operation, hospitals that are able to use Sodium Gluconate should take the medicine at this time, so that the patient can quickly regain spontaneous breathing and avoid muscle weakness.
Adverse events and complications, such as respiratory obstruction, respiratory depression, pulmonary complications, carbon dioxide retention, hypoxia, etc.
On the other hand, postoperative pain is the main cause of refusal to eat, depression and delayed getting out of bed.
The guidelines put forward higher requirements for postoperative analgesia.
The guidelines recommend avoiding the use of opioids and adopting multi-modal analgesia with non-steroidal anti-inflammatory drugs as the core as much as possible to avoid the side effects of each drug to the greatest extent possible .
If the patient cannot achieve satisfactory analgesia with oral medications, combined spinal/epidural analgesia or abdominal transverse plane block should be combined.
Finally, in order to accelerate the recovery of patients' gastrointestinal function and reduce the risk of thrombosis and insulin resistance, the guidelines encourage patients to get out of bed as soon as possible.
If the patient has no major complaints of nausea and vomiting, he can start drinking a small amount of water 4 hours after the operation.
If oral fluids can be tolerated, the intravenous infusion should be stopped as soon as possible on the first day after the operation. If clinical rehydration is needed, the physiological maintenance amount should be given in the case of ignoring the surgical loss, 25-30 ml/kg per day, and sodium intake should not exceed 70-100 mg/d.
Throughout this edition of the guide, it is not difficult to feel the importance of teamwork: a team led by surgery, and a team of nursing and anesthesia will allow patients to have a more ideal surgical experience.
ERAS attaches great importance to pain management throughout the whole process.
The anesthesiology department will minimize the stress caused by pain during the preoperative and postoperative multimodal analgesia.
In addition, the anesthesia team will reduce the pneumoperitoneal pressure during the operation during the operation and after the operation.
The precise control of using Sodium Gluconate to quickly reverse the residual muscle relaxation satisfies the surgeon’s requirements on the surgical field, reduces the incidence of postoperative pulmonary complications in patients, and further reduces the pneumoperitoneum caused by the pneumoperitoneum.
pain.
I hope that this interpretation can convey some new ERAS concepts to the perioperative team of colorectal surgery and apply the ERAS consensus to clinical practice, so that patients with colorectal diseases can achieve ideal analgesia, reasonable deep muscle relaxation and precise reversal Really fast recovery.
-End-
The theory of Rapid Rehabilitation Surgery (ERAS) was first proposed by Danish surgeon Kehlet in 2001.
This perioperative multi-mode optimization plan can achieve the goal of reducing complications, reducing postoperative pain, shortening the length of hospitalization and reducing costs through a series of preoperative, intraoperative and postoperative measures, and returning to normal life as soon as possible.
In 2005, the first ERAS consensus on colorectal surgery was released, and the process of minimally invasive colorectal surgery has developed more rapidly.
In 2018, the ERAS Association updated the ERAS Consensus on Colorectal Surgery and published the fourth edition of the "Perioperative ERAS Guidelines for Elective Colorectal Surgery" (hereinafter referred to as the guidelines).
This edition of the guidelines summarizes and systematically reviews and systematically review evidence-based medicine evidence such as meta-analysis, randomized controlled trials, and prospective cohort trials related to colorectal rapid rehabilitation surgery published between January 2012 and October 2017.
The recommended classification has brought the latest clinical practice basis to colorectal surgeons.
Today we will take stock of updates to the fourth edition of the guide.
1 Before admission: Patient education makes you less anxious and understands more.
The guidelines recommend that patients receive patient education before admission.
The purpose is to let patients have a complete understanding of surgery, so as to reduce anesthesia and surgery-related anxiety and correctly understand surgery-related pain.
In addition, patient education can increase the patient's sense of participation throughout the treatment process, thereby obtaining psychological support.
In addition to the details of the operation and the instructions for hospitalization, the requirements for quitting smoking and drinking should also be communicated in this procedure.
2 Before surgery: Pay attention to prevent nausea and vomiting.
The quality of evidence is stronger than before.
Surgery is undoubtedly a stressful event for patients.
Therefore, the focus of preoperative work is to reduce the impact of surgery on the normal physiological state of patients through all aspects of preparation.
influences.
Because preoperative malnutrition increases the morbidity and mortality of postoperative complications, it is also related to the poor prognosis of cancer patients.
Therefore, positive assessment of the patient's preoperative nutritional status and timely correction will help to achieve rapid recovery.
At present, it is recognized by the academic community that the NRS 2002 score is used to evaluate the objective nutritional risk of patients, and subjective scoring tools such as SGA, PGSGA and MUST are added to improve the nutritional risk assessment.
In addition, two large clinical studies believe that the preoperative plasma albumin level is also related to the patient’s Mortality and mortality are related, so it is also recommended to check the patient's plasma albumin level before surgery and actively correct hypoalbuminemia.
In addition, anemia is very common in patients with malignant tumors, and it is also an important factor leading to surgical complications, death and poor prognosis.
Therefore, anemia should be actively corrected before surgery, try to improve the hemoglobin concentration in a relatively short period of time by intravenous infusion of a new type of iron, and avoid blood transfusion if not necessary.
In terms of preoperative anesthesia, considering that the widespread anxiety of patients may lead to an increase in the need for intraoperative sedatives and postoperative complications, it is necessary to give patients preoperative benzodiazepines to reduce anxiety.
At the same time, adequate communication before surgery and the company of family members can also alleviate the patient's anxiety.
In terms of drug selection, because elderly patients take benzodiazepines, there is a certain cognitive risk.
Therefore, if the patient has serious anxiety and has to take medication, it is recommended to use short-acting drugs to avoid adverse effects on the neuropsychiatric of elderly patients.
.
There is evidence that melatonin also has a good anti-anxiety effect with fewer side effects, so it is recommended for clinical use.
In this guide, the preoperative preparation plan to prevent nausea and vomiting (PONV) has changed from the recommended level in 2012, from low to high.
Severe PONV can cause dehydration, delay nutritional intake, increase the possibility of gastric tube placement, and indirectly prolong hospital stay and increase medical costs.
Therefore, patients with risk factors who are about to undergo colorectal surgery should choose dual or triple combination drugs according to the number of risk factors.
When the patient has nausea and vomiting, remedial medication should be used on the basis of preventive medication.
In addition to the preoperative requirements mentioned above, avoiding mechanical bowel cleansing, preoperative preventive use of antibiotics, correcting water and electrolyte disorders, and giving non-alcoholic carbohydrate beverages 2 hours before surgery are also recommended in the guidelines.
3 During operation: In the era of minimally invasive surgery, deep muscle relaxation and low pneumoperitoneum pressure are more in line with the ERAS concept.
The fourth edition of the guidelines emphasized the development trend of minimally invasive colorectal surgery at the beginning.
In fact, in many countries, minimally invasive colorectal resection (MIS) has replaced the traditional open surgery and has become the standard treatment.
MIS is not only less traumatic, but also has a lower incidence of trauma-related complications (such as incisional hernia and intestinal adhesions caused by surgery).
The patient's body fluids are also less traumatized to avoid unnecessary loss.
In addition, the postoperative pain score of MIS is lower than that of open surgery, which minimizes the use of opioid analgesics and allows patients to recover faster gastrointestinal function after surgery.
The most direct difference between minimally invasive surgery and open surgery is the difference in the surgical field.
In the past, surgical operations often required an increase in pneumoperitoneum pressure to meet the exposure of the surgical field under the conditions of minimally invasive surgery.
Although this method can meet the needs of free surgical operation, high pneumoperitoneal pressure will increase the circulatory burden, hinder ventilation and reduce the blood flow of important organs in the abdominal cavity (such as the kidney).
This method is not beneficial to the patient in the long run.
The short-term prognosis is also a hidden danger to the occurrence of postoperative pulmonary complications.
The fourth edition of the guidelines proposes anesthesia strategies to achieve deep muscle relaxation during surgery and strengthen neuromuscular testing.
There is evidence that deep muscle relaxation can meet the win-win situation of low pneumoperitoneum pressure and satisfactory operation space: because the patient is in a state of deep muscle relaxation, the resistance of the muscles against the pneumoperitoneum is greatly reduced, and satisfactory exposure can be achieved under the state of low pneumoperitoneum.
On the one hand, reducing the intra-abdominal pressure below 10-12mmHg can reduce the impact of pneumoperitoneum on circulation and breathing, minimize aortic afterload, maintain renal blood flow, and reduce the peak pressure of the ventilator. In the past, because anesthesiologists were concerned about the unavoidable residual muscle relaxation in the application of deep muscle relaxation, the application and promotion of deep muscle relaxation was relatively limited.
However, with the popularization of Sodium Gluconate in clinical applications, the residual concerns of muscle relaxation have been resolved.
Sodium sugammadex can accurately antagonize and reverse the muscle relaxation effects of rocuronium and vecuronium, significantly reduce the risk of residual muscle retention, and does not bring the anticholinergic side effects of the traditional drug neostigmine, avoiding The influence of autonomic nerves and heart rate.
In addition, in order to minimize the occurrence of postoperative pain in patients, the guidelines also recommend that the anesthesiology department adopt multi-modal analgesia.
Use general anesthesia or combined epidural anesthesia as much as possible to meet surgical requirements and antagonize the stress response caused by trauma.
In terms of medication, the guidelines suggest that short-acting sedatives, short-acting opioid analgesics and muscle relaxants should be the first choice for general anesthesia, such as propofol, remifentanil, sufentanil, etc.
, muscle relaxants can be considered Curonium, cis-atracurium, etc.
4 Postoperative: Pay attention to postoperative pain management and accelerate the recovery of intestinal function.
After the operation, hospitals that are able to use Sodium Gluconate should take the medicine at this time, so that the patient can quickly regain spontaneous breathing and avoid muscle weakness.
Adverse events and complications, such as respiratory obstruction, respiratory depression, pulmonary complications, carbon dioxide retention, hypoxia, etc.
On the other hand, postoperative pain is the main cause of refusal to eat, depression and delayed getting out of bed.
The guidelines put forward higher requirements for postoperative analgesia.
The guidelines recommend avoiding the use of opioids and adopting multi-modal analgesia with non-steroidal anti-inflammatory drugs as the core as much as possible to avoid the side effects of each drug to the greatest extent possible .
If the patient cannot achieve satisfactory analgesia with oral medications, combined spinal/epidural analgesia or abdominal transverse plane block should be combined.
Finally, in order to accelerate the recovery of patients' gastrointestinal function and reduce the risk of thrombosis and insulin resistance, the guidelines encourage patients to get out of bed as soon as possible.
If the patient has no major complaints of nausea and vomiting, he can start drinking a small amount of water 4 hours after the operation.
If oral fluids can be tolerated, the intravenous infusion should be stopped as soon as possible on the first day after the operation. If clinical rehydration is needed, the physiological maintenance amount should be given in the case of ignoring the surgical loss, 25-30 ml/kg per day, and sodium intake should not exceed 70-100 mg/d.
Throughout this edition of the guide, it is not difficult to feel the importance of teamwork: a team led by surgery, and a team of nursing and anesthesia will allow patients to have a more ideal surgical experience.
ERAS attaches great importance to pain management throughout the whole process.
The anesthesiology department will minimize the stress caused by pain during the preoperative and postoperative multimodal analgesia.
In addition, the anesthesia team will reduce the pneumoperitoneal pressure during the operation during the operation and after the operation.
The precise control of using Sodium Gluconate to quickly reverse the residual muscle relaxation satisfies the surgeon’s requirements on the surgical field, reduces the incidence of postoperative pulmonary complications in patients, and further reduces the pneumoperitoneum caused by the pneumoperitoneum.
pain.
I hope that this interpretation can convey some new ERAS concepts to the perioperative team of colorectal surgery and apply the ERAS consensus to clinical practice, so that patients with colorectal diseases can achieve ideal analgesia, reasonable deep muscle relaxation and precise reversal Really fast recovery.
-End-
