By Laura Landro
Updated March 31, 2015 9:17 a.m. ET
Clear liquids and pain meds before surgery, less IV fluid during and fewer narcotics afterward
Hospitals are replacing traditional surgery preparation and recovery practices with “enhanced recovery” protocols amid evidence of improved patient health. WSJ’s Laura Landro reports.
Hospitals are starting to abandon the time-honored drill for surgery patients— including fasting, heavy IV fluids, powerful post-op narcotics and bed rest—amid growing evidence that the lack of nutrients, fluid overload and drug side effects can do more harm than good.
Instead, they are turning to “enhanced recovery” protocols that are easier on patients, help them get better faster with fewer infections and other complications and reduce health-care costs.
The changes, pioneered in Europe over the past 15 years, now are being adopted more widely in the U.S. Though the evidence is strongest in colorectal surgery, the approach is being used with an increasing range of procedures including hip fracture and joint replacements and surgeries for bladder, pancreas, liver and breast cancer.
Hunger and thirst from presurgical fasting can add to patients’ stress and anxiety, and cause weakness as well as postoperative nausea. Side effects of fluid retention, narcotics and immobility can interfere with getting bodily functions back to normal, resulting in longer, harder recoveries overall. With traditional regimens, patients can remain in the hospital for 10 days or more with complication rates of up to 48% and an average $10,000 in additional costs, according to researchers at Duke University School of Medicine.
With enhanced recovery protocols, patients still can’t eat after midnight before an early morning surgery, but two or three hours before surgery they do get a carbohydrate-loaded drink fortified with electrolytes, minerals and vitamins. They are pretreated for pain with nonnarcotic painkillers and epidurals that are kept in place postoperatively. With careful monitoring, patients receive only necessary levels of IV fluid during surgery. Soon afterward they get out of bed to walk and may ingest solid food, and they are discharged earlier with careful instructions for home care.
“This is contradictory to the way we’ve practiced for 50 years, but it is becoming more and more evident that this really is more effective and better for patients,” says Traci Hedrick, assistant professor of surgery at the University of Virginia. “Surgery is already a significant trauma on the body and we want to help keep patients as normal as possible for as long as possible.”
Dr. Hedrick is co-author of a study published online in February in the Journal of the American College of Surgeons that found that the new protocol, used in colorectal-surgery patients at the UVA health system, helped reduce the length of hospital stay by 2.2 days compared with a control group who had conventional treatment. It also reduced complications by 17% and increased patient satisfaction with pain control by 55%. There was a cost savings of $7,129 per patient.
Dr. Hedrick acknowledges it has been a “struggle” to get some surgeons and anesthesiologists to change ingrained habits but they are often convinced by the results: “You just have to see one patient for the first time and how dramatically different they look and feel than in the past,” she says.
A 2011 study in JAMA Surgery found that despite the clear benefits of enhanced recovery protocols, old traditions prevail. To increase adoption, the American College of Surgeons is sponsoring a national initiative led by experts including Julie Thacker, assistant professor of surgery at Duke University School of Medicine and medical director of the enhanced recovery program at Duke University Hospital, which has been able to reduce hospital stays and readmissions with the approach. Dr. Thacker co-founded the nonprofit American Society for Enhanced Recovery last year to educate operating-room teams and says many traditional practices have been disproved.
Surgeons adopted the practice of infusing fluid, for example, after wartime studies showed it improved survival in trauma patients, but it isn’t necessary in the average patient, Dr. Thacker says. “Giving extra IV fluids to overcome the starvation we’ve imposed on patients leads to worse outcomes,” such as preventing bowel function from returning to normal, she says.
Rules on fasting before surgery are based on assumptions that anesthesia reactions might cause patients to throw up during a procedure and hamper breathing, but research has shown clear liquids within two hours actually decreases that risk, according to John Abenstein, president of the American Society of Anesthesiologists and a Mayo Clinic anesthesiologist. OR teams are sometimes reluctant to adopt the less-restrictive policies out of concern patients won’t follow directions and come in for surgery having had a glass of milk or cola, and then surgery has to be delayed, Dr. Abenstein says. But when patients consume clear liquids correctly, they feel much better after surgery, he says.
Charles Suñé, a 57-year old technology product manager in Chapel Hill, N.C., had surgery at age 17 and again in his mid-30s for Crohn’s disease, a chronic inflammatory condition of the digestive tract. He remembers in both cases “waking up feeling like I was hit by a bus, and the morphine couldn’t kick in fast enough.” Both times, he suffered from retained fluid in his legs and had to spend a week in the hospital consuming only a liquid diet.
When his condition flared up again, Mr. Suñé dreaded a third surgery. But last year, after two emergency-room visits, he realized he couldn’t put it off any longer. Dr. Thacker reassured him the new protocols would make it easier. Two hours before surgery, he drank a carbohydrate-rich beverage. To prevent pain, he took nonnarcotic medications including Tylenol, and doctors inserted an epidural, which stayed in place for two days after surgery. His IV fluids were monitored carefully during surgery so he received the ideal amount.
Mr. Suñé says he was so surprised not to feel pain after the procedure that he was texting his friends from the hospital and needed only a minimal amount of oral narcotics compared with past procedures. He was up and walking the first day after surgery, and able to resume eating solid food. “This was a completely different experience for me compared to my two previous surgeries, and my recovery was really fast,” he said.
Kaiser Permanente Northern California is currently rolling out the enhanced recovery protocol in its 21 medical centers, focusing first on colorectal surgery and hip fracture patients. It plans to expand the program soon to total joint replacement, according to Efren Rosas, assistant physician-in-chief, hospital operations, at Kaiser’s San Jose Medical Center. Kaiser provides patients with educational videos and brochures, and a calendar with a detailed checklist of what to expect with the new protocols.
Immediately after surgery, when pain is often worst, patients are still offered narcotic medications, Dr. Rosas says. But presurgical medication and injections to block pain can minimize the use of narcotics, eliminating side effects such as constipation, nausea and dizziness.
Christina Solis, a nurse and performance improvement adviser at Kaiser Permanente, says OR teams have to work together to make sure the enhanced recovery protocol is followed “from the time the patient walks in for the first appointment until after discharge.” “This care is truly providing different and better outcomes for patients,” she says.