ERAS Mediation Paper

Prediction of fluid responsiveness has been investigated to prevent fluid overload because excessive peri-operative fluid administration can be a contributory factor to postoperative complications, prolonged length of hospital stay, organ failure and mortality1-4.

On 01/27/2016, I observed about 22 patients in Postanesthesia Care Unit. Some of the patients were observed after surgeries while others were observed after endoscopy. During my shift, I observed patients awaiting recovery for removal of kidney stones, malignant melanoma (removal of moles), Endometrial Biopsy (EBX), superficial femoral artery (SFA), Hernia repair, Oophorectomy (ovary removal surgery), Cardiorrhaphy (Ventricular repair), Cystolithalopaxy (bladder stone removal), gall stone removal, Ectopic pregnancy surgery, and leg surgery.

The appropriate assessment of patients prior to surgery to identify coexisting medical problems and to plan peri-operative care is of increasing importance. The goals of peri-operative assessment are to identify important medical issues in order to optimise their treatment, inform the patient of the risks associated with surgery, and ensure care is provided in an appropriate environment secondly to identify important social issues which may have a bearing on the planned procedure and the recovery period and to familiarise the patient with the planned procedure and the hospital processes.(American Society of Anaesthesiologists)

ERAS is a perioperative experience/protocol with a main goal to decrease post-op complications such as post-operative ileus, decrease cost and length of stay, and improve patients’ experience and outcomes for major abdominal surgeries. Due to the copyright of ERAS, ISCR (Improving Surgical Care and Recovery) is the acronym used across many hospitals. The protocol was launched by the Agency for Healthcare Research and

It is important that the type of stroke is diagnosed quickly to reduce the damage done to the brain and also to determine the right type of treatment because one treatment for one kind of stroke can be harmful to someone who has had a different kind. A number of different medications may be given at the hospital to help break up the clot and prevent the formation of new clots. For Ischemic stroke the treatment can begin with drugs to break down clots and prevent further ones from forming. Aspirin can be given, along with an injection of a tissue plasminogen activator (TPA). TPA works by dissolving clots but it needs to be injected within 4.5 hours of stroke symptoms once they have presented themselves. Hemorrhagic stroke treatment can begin with drugs being given to reduce the pressure in the brain, overall blood pressure, prevent seizures and prevent sudden constrictions of blood vessels.(http://www.mayoclinic.org/diseases-conditions/stroke/diagnosis-treatment/treatment/txc-20117296) Because strokes are life-changing events that can affect a person both physically and emotionally, temporarily or permanently. After a stroke,

The agenda was quite clear that during their observations the recovery showed needs were decreased according to age and BMI. They stated older patients were in need of more assistance and longer stay in the hospital as opposed to younger adults. I found it interesting that they saw patients with bilateral knees had decreased needs and that unilateral were in need of more assistance before discharge. Managing pain was their first priority during research and rehabilitation, followed by instructing care of their own surgical wound. The aim of this study was to actively reinforce assessment and management after this procedure and giving guidance to those in health care.

My assessment of practice evidence for Term B is based on a case study of a particular patient during her perioperative journey from the ward before the surgery until she was ready to be sent back on the ward post operative on the 25th February, 2017. I followed a female patient who was having a surgical procedure called Laparoscopic Cholecystectomy. Cholecystectomy is the removal of the gall bladder and usually performed as a day case procedure. The operaion is carried out under a general anaesthetics. A telescope the width of a small finger is placed into the abdomen through a small cut at the navel. In order to create spare around the organs within the abdomen and provide the surgeon with a clear view it is necessary to use carbon

Enhanced recovery after surgery (ERAS) are a relatively new set of protocols arising in the 1990’s which have since been coined the gold standard in surgical patient care. They have been increasing adopted in because overall research has shown them to be a safe and cost effective way of reducing length of hospital stay and positive patient outcomes. ERAS protocols are threaded throughout the perioperative care, including pre, intra and post-operative phases. I will analysis two research papers which highlight the use of ERAS protocols and define a variety of protocols and focus on four ERAS protocols which are commonly used in surgical nursing.

When compared to conventional surgical procedures, minimally invasive surgeries are improving patient experiences in a variety of ways: From a shorter hospital stay, to smaller incisions and a quicker recovery, MIS allows patients to return to their normal activities much sooner than is typically seen with conventional procedures. Through the use of minimally invasive surgery, we can minimize the emotional and physical impact that surgery has on our patients.

Despite recent advances in information regarding perioperative care, postoperative pain continues to go undermanaged. Postoperative pain is the pain patients experience after a surgical procedure. According to Gan, 80% of all people who undergo surgeries experience postoperative pain, and 75% of them rate their pain at a moderate, severe, or extreme level (as cited by Cooney, 2016). Furthermore, inadequately managed pain can lead to patient dissatisfaction, decreased patient outcomes, and overall higher cost of care (Penprase, Brunetto, Dahmani, Forthoffer & Kapoor, 2015). In order to provide higher quality pain management,

This article looks at negative effects after surgery that can be avoided by ambulating patients early. The purpose of this study is to provide evidence to the outcomes of mobilizing patients versus not mobilizing them. The article states that

367). On the side of expert opinion, the CMS has had discourse regarding the potential broadening of events related to inadequate VTE prevention for both surgical procedures and medical patients (Maynard, 2016, p. 4).

With post surgical patient there needs to be wound monitoring, signs and symptoms of infections, incentive spirometry and deep breathing exercises needs to be enforced, as well as medication education especially for the patient who have had a orthopedic surgery and are an anticoagulant.

Long term goal: Patient will have improved cerebral perfusion with no mental status change or complications and good capillary refill.

Outcomes is a difficult parameter to deal with.  I would say my average patient is in their middle to late seventies.  Since transitioning to Robotic assisted surgeries my incisions usually end up at about four centimeters in size for extrication of the specimen. This has markedly improved pain, we no longer require epidurals.  Instead we use local anesthesia blocks.  This decreases the LOS in the ICU.  This is part of an Enhanced Recovery After Surgery (ERAS) protocol which promotes clear protein drinks until two hours prior to the start of anesthesia.  With this we avoid nasogastric tubes, they are given gum to chew to help wake up their gastrointestinal system, we ambulate the patient on the same day as surgery.  We start feeding the clear protein drinks on the first day after surgery, minimize the amount of narcotics, and advance them to walking and eating on a regimented schedule.    Once the patient is eating a regular diet, ambulating and passing bowel movements and pass a Physical Therapy assessment, they are deemed stable for discharge.  For the readmission issues, we seem to have issues with the cardiac service.