Implementation and Compliance to an Enhanced Recovery Protocol for Liver Resections 1 2 1,2,3 Manav Shah , Neda Amini , and Matthew Weiss 1Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
2Northwell Health, North Shore/Long Island Jewish General Surgery, Manhasset, NY, USA 3Northwell Health Cancer Institute, Lake Success, NY, USA
Background
Results
An enhanced recovery protocol (ERP) is an evidence-based pathway designed to achieve early recovery and optimize patient outcomes following surgical procedures1,2. ERPs are gaining traction in the surgical world as they are associated with fewer complications, shorter hospital stays, and lower healthcare costs3,4. Standardizing care during the perioperative period in this manner eliminates the variability in surgical care that currently exists at many institutions, improving both quality and patient outcomes1,5.
Figure 1. Organizational Schematic of the Northwell Liver ERP. Liver resections were separated into three categories with different target discharge times. The pathway was defined from day before surgery to postoperative day 5.
Accordingly, at Northwell, system-wide ERPs are currently being utilized for various operations, such as colorectal and pancreas cancer resections. A standardized protocol for liver resections, however, currently only exists at a single site and is outdated. System-wide implementation of an updated ERP based on new guidelines for liver surgery would represent the first of its kind to exist across a large health system.
Conclusions
Liver Resection
Major Open
Target Discharge Day: 4-7
MIS (Laparoscopic or Robotic)
Minor Open
Target Discharge Day: 2-5
Target Discharge Day: 1-4
Hypothesis Implementation of an up-to-date ERP for liver resections will improve quality of care and patient outcomes across a large health system.
Methods The Enhanced Recovery After Surgery (ERAS®) Society consensus statements describe perioperative recommendations for various surgical operations6. These expert-produced guidelines have become increasingly adopted worldwide as several studies have validated their efficacy. The first ERAS guidelines for liver surgery were released in 2016. Since then, several seminal studies evaluating interventions in liver surgery have been published, leading to the ERAS Society releasing a new set of guidelines in 20227. We conducted a targeted search of PubMed/MEDLINE, Web of Science, and Google Scholar for literature on the perioperative care of patients undergoing liver surgery. We further evaluated the reference lists of selected articles and used literature from our own collections. We expanded our search to include all patients based on the extent of liver resection (major vs. minor) and the surgical technique used (open vs. laparoscopic vs. robotic). The recent 2022 ERAS guideline statement for liver surgery was used as the foundation for the development of our ERP. ERAS recommendations that were not included in the existing pathway were incorporated when in concordance with our literature search. The findings of our targeted search were also added, refining various elements of the pathway.
Day Before Surgery
Pre-Op Area/Day of Surgery
POD 0
POD 4
POD 2 POD 1
POD 3
POD 5
Figure 2. Descriptors and Key Modifications to the Northwell Liver ERP. Descriptor
Modifications
Diet
• Normal PO intake until 6 hours pre-op • Carbohydrate loading dose (CLD) evening before and 2-4 hours before surgery • Removed CLD after midnight
Fluids Pain
• Scopolamine patch should be avoided in the elderly • Removed pre-op Celebrex • Transition to PO pain meds for Minor Open and MIS • Schedule for NSAID and acetaminophen administration • Removed gabapentin Figure 7: Independent CRISPR knockout•of CDK4 or CDK6 Supplemental Added single pre-op dose of methylprednisolone does not cause dropout in most breast cancer cell lines • Removed Docusate studied. Medications Activity Labs • Added maintenance of post-op glycemic control Phosphate Repletion Device and Procedures
Shown below is a visual representation of the finalized Northwell Liver ERP: Description
Day Before Surgery
Pre-Op Area/Day of POD 0 (Day of Surgery) Surgery
DIET
Normal PO intake until 6 hours preop, CLD evening before surgery
Regular diet the day Limited Clears <30cc before, CLD 2-4 hrs before surgery after midnight, Gatorade 2 hrs before surgery
POD 1 (Review Discharge Criteria POD 2 (Minor open and MIS: and consider transfer to floor, discharge if criteria met) MIS: discharge if criteria met) Unlimited Clears Regular
POD 3 (discuss and consider discharge if meeting goals)
POD 4 (discharge)
POD 5 (discharge)
Regular
Regular
Regular
HL
HL
IV d/c
IV PCA Consider D/C IVPCA Discontinue Ketorolac; start Ketorolac 15mg IV q6hrs x 72hrs - Gabapentin 100 mg po TID Ibuprofen 400 mg po q6 hrs; must have the following: UOP > Tramadol 50 mg po q4 hrs PRN; Gabapentin 100 mg po TID; 0.5cc/kg/hr, Cr < 1.5, Age < 70 Oxycodone 5-10mg PO q4h PRN Tramadol 50 mg po q4 hrs Minor Open: transition to PO [only for pain not controlled by PRN; Oxycodone 5-10mg PO pain meds in PM if tolerating diet PO Tramadol]; Hydromorphone q4h PRN [only for pain not MIS: transition to PO pain meds 0.5-1mg IV q3h PRN [only for controlled by PO Tramadol]; in AM if tolerating diet pain not controlled by oral Hydromorphone 0.5-1mg IV Schedule NSAIDs & APAP unless meds]; q3h PRN [only for pain not medically contraindicated (hold Consider Ketorolac 15mg IV controlled by oral meds]; NSAIDs for platelets <100 or q6hrs x 72hrs - must have the Remove scopalamine patch Creatinine >1.5, hold APAP for following: UOP > 0.5cc/kg/hr, Cr LFTs >500, max APAP < 1.5, Age < 75 2,000mg/day)
Discharge scripts sent to pharmacy the night before discharge: Tramadol 50mg PO
Discharge pain meds: Tramadol
Magnesium Sulfate 4G daily
Magnesium Sulfate 4G daily Docusate 100mg BID Senna 8.6mg nightly Milk of Mag 30ml BID PRN Resume home medications
Docusate 100mg BID Senna 8.6mg nightly Milk of Mag 30ml BID PRN Resume home medication
Evaluate orthostatics prior to floor transfer Laps x3 IS: 10x per hour Pulmonary Toilet
Laps x4 IS: Laps x5 10x per hour Pulmonary Toilet IS: 10x per hour Pulmonary Toilet
FLUIDS
Strict Fluid NS- Goal: Start at 150cc/hr NS @42cc/hr Restriction- Hep Lock Goal UOP 0.5 cc/kg/hr (24 AVOID COLLOID/ALBUMIN hrs) AVOID COLLOID/ALBUMIN
PAIN
Scopolamine patch (should be avoided in the elderly); Celebrex 200mg PO x1
SUPPLEMENTAL MEDICATIONS
Single pre-op dose of methylprednisolone 500mg (no recommendation formulated for diabetic patients)
ACTIVITY
No restrictions
IV PCA Consider Ketorolac 15mg IV q6hrs x 72hrs - must have the following: UOP > 0.5cc/kg/hr, Cr < 1.5, Age < 70
D 5 1/2 + 20K @ 42cc/hr
Page 1 OOB to chair 6 hours after operation Orthostatics 1st time OOB IS: 10x per hour Pulmonary Toilet
Docusate 100mg BID Senna 8.6mg nightly Milk of Mag 30ml BID PRN Resume home medication
50mg PO q4h PRN until followup apt; Ibuprofen 400mg PO q6h until follow up apt; Gabapentin 100mg q4h PRN until follow up apt; TID for 1 week (not to exceed a Ibuprofen 400mg PO q6h until follow up apt; Gabapentin 100mg total of 2 weeks); Oxycodone 510mg PO q4h PRN (only if patient is TID for 1 week; Oxycodone 510mg PO q4h PRN (only if patient taking narcotics in house) is taking narcotics in house)
Laps x6 IS: Activity at home: 10x per hour Pulmonary Toilet No lifting >10lb for 8 weeks Return to work in 10 weeks Continue walking at home No driving while on narcotics Go back to hobbies as soon as you can
LABS
CMP, CBC, PT/INR, type and cross 2 units
CMP, CBC, PT/INR, phos - on CMP, CBC, PT/INR, Phos BID draw CMP, CBC, PT/INR, Phos BID arrival and with PM labs until LFTs and INR have peaked draw until LFTs and INR have No lactate blood draws and starting to normalize and peaked and starting to Maintenance of post-op Phos has stabilized normalize and Phos has glycemic control <150md/dl stabilized (<8.3mmol/l), if not maintained consider insulin therapy
CMP, CBC, PT/INR, Phos BID CMP, CBC, Phos daily when No labs on day of discharge draw until LFTs and INR have LFT, INR and Phos criteria met peaked and starting to normalize and Phos has stabilized
Phosphate Repletion
NA
NA
Phos <1.0:Kphos Neutral 500mg QID and IV Phos 30mmol Phos 1.0-1.4: Kphos Neutral 500mg QID and IV Phos 20mmol Phos 1.5-2.4: Kphos Neutral 500mg QID and IV Phos 10mmol Phos 2.4-3.9: Kphos Neutral 250mg BID Phos >4.0: Stop Phos replacement
Phos <1.0:Kphos Neutral 500mg QID and Phos <1.0:Kphos Neutral 500mg QID IV Phos 30mmol and IV Phos 30mmol Phos 1.0-1.4: Kphos Neutral 500mg QID Phos 1.0-1.4: Kphos Neutral 500mg and IV Phos 20mmol QID and IV Phos 20mmol Phos 1.5-2.4: Kphos Neutral 500mg QID Phos 1.5-2.4: Kphos Neutral 500mg and IV Phos 10mmol QID and IV Phos 10mmol Phos 2.4-3.9: Kphos Neutral 250mg BID Phos 2.4-3.9: Kphos Neutral 250mg Phos >4.0: Stop Phos replacement BID Phos >4.0: Stop Phos replacement
Phos <1.0:Kphos Neutral 500mg QID and IV Phos 30mmol Phos 1.0-1.4: Kphos Neutral 500mg QID and IV Phos 20mmol Phos 1.5-2.4: Kphos Neutral 500mg QID and IV Phos 10mmol Phos 2.4-3.9: Kphos Neutral 250mg BID Phos >4.0: Stop Phos replacement
Device and procedures
NA
Maintain foley Maintain IVAC SCDs while in bed
Maintain foley Maintain IVAC SCDs while in bed Discontinue arterial line if MAP > 80 x 4 hrsmust d/c before going to floor status
d/c foley DTV 8 hours after foley removed Maintain IVAC SCDs while in bed
d/c IVAC SCDs while in bed
Maintain IVAC SCDs while in bed
If Phos >4.0- do not send home with phos replacement Phos <4.0 send home with Kphos Neutral 250mg BID x 1 TOTAL week (including hospitalization) IF pt requires IV replacement within 24 hours of d/c, consider 500mg BID-QID and/or 2 week replacement
Given the size of our health system, variability in liver surgery across sites is inevitable. To optimize quality and patient outcomes, strategies such as systemwide ERPs must be employed. Here, we present a functional liver ERP specifically designed for the largest health system in New York, redefining the scope of standardized care and quality improvement.
Future Directions • Refinement of the ERP following input from Northwell liver surgeons, with the goal of harmonization and a set protocol to be used system-wide • Education for surgical staff and providers regarding key pathway elements • Measurement of pathway compliance using scorecard sheets and EMR order sets
Resources 1. Kowa CY, Jin Z, Gan TJ. Framework, component, and implementation of enhanced recovery pathways. J Anesth. 2022;36(5):648-660. doi:10.1007/s00540-022-03088-x 2. Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice?. Can Urol Assoc J. 2011;5(5):342-348. doi:10.5489/cuaj.11002 3. Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AF. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg. 2014;101(3):172-188. doi:10.1002/bjs.9394 4. Noba L, Rodgers S, Chandler C, Balfour A, Hariharan D, Yip VS. Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Improve Clinical Outcomes in Liver Surgery: a Systematic Review and Meta-Analysis. J Gastrointest Surg. 2020;24(4):918-932. doi:10.1007/s11605-019-04499-0 5. Sheetz KH, Ibrahim AM, Nathan H, Dimick JB. Variation in Surgical Outcomes Across Networks of the Highest-Rated US Hospitals. JAMA Surg. 2019;154(6):510-515. doi:10.1001/jamasurg.2019.0090 6. Brindle M, Nelson G, Lobo DN, Ljungqvist O, Gustafsson UO. Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines. BJS Open. 2020;4(1):157-163. doi:10.1002/bjs5.50238 7. Joliat GR, Kobayashi K, Hasegawa K, et al. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J Surg. 2023;47(1):11-34. doi:10.1007/s00268-022-06732-5