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Enhanced Recovery in Major Bowel Surgery

Enhanced recovery programmes or fast track protocols form a novel system of care for patients undergoing major abdominal surgery.  Many of the ways in patients are managed contradict previously learnt doctrines and therefore represent radical changes which can be difficult for doctors, nurses and patients and relatives to accept.

This article outlines the important elements of this system of care and discusses the problems which are encountered during implementation.

The advantages of this system of care has been shown in many studies.  Not only do patients get home earlier, suffer less complications, and the whole journey through the process of major surgery becomes much better tolerated. 

1.  Preparation of patient and relatives in clinic prior to their hospital stay.

Clearly this is important to inform the patients of the plans regarding their care, the role they play in their recovery with regards to early eating, early walking around and hopefully early discharge home without complications. This is essential part of the process and forms part of the consent of the proposed operation.

2. Education of allied health professionals.

The ward nursing staff, physiotherapists, and dietetics staff have a significant role to play as they will be responsible for encouraging the patient to eat and get out of bed often when they do not want to. 

3. Anaesthetists role in pain control and optimised peri-operative fluids.

Anaesthetists must be in from the start.  Part of the programme involves administration of preoperative carbohydrate drinks up to 2 hours prior to surgery, these leave the stomach empty in two hours and are therefore safe.  The leaves the nil by mouth for over 6 hours or over night.  If the anaesthetist is not aware clearly the case is delayed of cancelled and the advantages not borne out.  Also intravenous fluids given peri- operatively are minimised or optimised according to the patients specific needs this process is greatly aided by special monitoring.  The use of high epidurals also helps the patient get up and about relatviely free of pain on the day of the operation.

4. Inertia and getting away from previously learnt doctrines.  

OLD HABITS DIE HARD.  It is very difficult for surgeons and all of the the other carers discussed above to change practises which for many have been lifelong.  However gradually seeing the benefits patients gain from this hard work encourages the whole team and slow progress is made.

Contact me via the website for further information, progress, successes and difficulties introducing the programme for my patients.