Ether– Resources for Anesthesia Research and Education

Colorectal Protocol with ERAS Elements

Drafted by: Alimorad G. Djalali MD

This protocol intends to streamline the perioperative management of colorectal patients by preventing unnecessary variations. Deviation from the protocol is in discretion of the anesthesiologist. All aspects of this protocol are based on best evidence available and have been tested on multiple colorectal patients.

IV access:
An 18 G peripheral IV is sufficient for common laparoscopic colorectal procedures. Both arms will be tucked to the side for most colorectal procedures so make an assessment if you may need a second IV.

Premedication:

  • 1-2 mg midazolam IV prior to moving the patient to the OR. The dose should be adjusted to age.

Many anesthesiologists avoid midazolam in elderly for fear of postoperative delirium. There is not any strong evidence to support this notion.

  • 25-50 mcg fentanyl can also be used to relax the patient prior to the procedure.

According to ERAS work group, low dose (10-20 mg) propofol is another option. Please avoid combinations of strong sedatives in elderly patients.

  • Per agreement with the surgical team, patients should take the following medications PO:

Gabapentin 600 mg, it will be continued for 5 days, 300 mg TID.

  • Entereg (alvimopan) 12 mg PO, to be continued 12 mg BID, until the bowel function recurs.
  • 1 g of acetaminophen PO. Will be continued by surgical service.
  • Celebrex, 200 mg PO.
  • Patients should be offered the oral meds as soon as they are on the stretcher.
  • Consider scopolamine patch in patients with high risk of PONV.
  • Please obtain consent for a TAP-Block in the preop-area, should patient’s pain level require one. Patients undergoing open surgery will have bilateral posterior TAP-Block with catheters preoperatively.

Please notice that patients are allowed to drink energy drinks up to 2 hours prior to surgery and solid food until midnight prior to surgery. Please don’t cancel the surgery if you are not comfortable starting the case. Page 13697 to discuss.

OR temperature:
The OR temperature should not be lower than 25 °C (77 F) when the patient enters the room.
Please pay attention to room temperature and turn the OR thermostat up if needed.
All OR tables should be equipped with a warming pad started before the patient enters the room. If the warming pad is used, a Bair Hugger is usually not necessary and may cause overheating of the patient.
All patients will have a temperature-Foley placed, and the temperature recorded accordingly.

Induction:
Regular induction as performed for other GA cases.

  • Fentanyl: 100-150 mcg
  • Propofol: 1-2 mg/ kg lean body mass (please titrate), propofol suppresses the sympathetic output and causes hypotension (relative hypovolemia).
  • Neuromuscular blocking agents as appropriate.
  • Phenylephrine and ephedrine as indicated, since anesthesia induction causes a relative hypovolemia, mostly not responsive to fluid boluses.
  • OGT placement
  • Ertapenem (1 g) is the antibiotic of choice for colorectal procedures at Stanford. It is re-dosed every 24 hours, re-dosing in the OR is not indicated. No dose adjustment is necessary if creatinine clearance is >30 mL/min/1.73 m2.

Maintenance of GA:

  • Volatile anesthetics less than 1 MAC, age adjusted. Usually a MAC of 0.7 is adequate! Please always put the patient’s age on the ventilator display so the computer can give you the age-related MAC value.
  • Use a BIS-monitor to guide you with the “right” concentration of volatile agents. Opioids, benzodiazepines, beta-blockers, lidocaine etc. reduce the MAC-requirements. BIS may help you avoid applying high concentrations of volatiles to patients. Be aware of artifacts; check the wave forms to make sure the numbers you see on BIS are accurate.

Please remember that ketamine increases the BIS-number. Any BIS-Number below 60 is indicative of deep anesthesia (higher numbers with ketamine).

  • Dilaudid (Hydromorphone) 0.5-1 mg at the beginning of the case to reach sufficient levels of opioids before the incision (different opinions exist on this issue, catching up with fentanyl is not the best option). Peak effect of dilaudid is obtained after 15 to 20 minutes. Fentanyl can be used subsequently during the case to account for additional pain medication requirements. Patients rarely need more than 250 mcg of fentanyl (frequently less is needed.) Some patients with prior opioid use and chronic pain may require more dilaudid or fentanyl. In those cases, methadone is also an option if you are familiar with its pharmacokinetics. Contact pager 13697 if you have questions regarding methadone.
  • Consider “multimodal analgesia”:
  •  Ketamine 30 mg (or 0.5 mg/kg IBW) before the incision, followed by 30 mg (or 0.25 to 0.5 mg/kg) every hour. An infusion with 30 mg/hr is possible. No additional dose 45 minutes before the end of the surgery. You could also use your own ketamine regimen. Important is to give patients ketamine, the dose is secondary.
  • Rescue TAP-Block in PACU for patients in pain, or posterior TAP-Block with catheter for open cases performed preoperatively. Also see the “premedication” section.
  • Hypertension that does not respond to opioids, i.e. not pain related, should be preferably treated with labetalol (5-10 mg) instead of increasing the volatile anesthetics concentration. Volatile agents should not be used as vasodilators!!

Hypertension at the beginning of the case can be related to pneumoperitoneum with CO2, and will usually subside on its own after 5 to 10 minutes.

  • Reversal of muscle relaxation as needed.
  • 4mg ondanzetron for PONV prophylaxis.
  • A single dose of Dexamethasone at the beginning of the procedure is an effective antiemetic (8 mg) and can also be used in well controlled diabetic patients.
  • Optional: Concomitant propofol drip in high risk patients for PONV.

Fluids:
In contrast to what many anesthesiologists think, colorectal operations do not require extensive fluid substitution:

  • NPO patients are not “dry” i.e. they are mostly euvolemic. Patients are allowed to drink up to 2 hours prior to operation.
  • Mechanical bowel-prep is obsolete in many institutions including ours.
  • IV fluids are “medications” per se, and their administration requires an indication.
  • Colorectal operations are performed mostly laparoscopically, hence, insensible loses are minimal.
  • Blood losses during colorectal procedures rarely exceed 150 ml.
  • In general, not much is known about the distribution of crystalloids and colloids in the human body. The same uncertainty is true regarding the benefit of one solution over the other.
  • Please try to restrict your IV fluids to 1500 ml. You could combine NS/LR with albumin 5%, for example 1000 ml of crystalloids combined with albumin. Most patients do not need any colloids. Beware of the latest critical publications regarding Hespan and its association with renal failure.  In rare cases, some patients may need more IV fluids, but usually not more than 2000 ml. A Goal-directed therapy in colorectal cases via PPV is not feasible since almost no patient will have an A-line. In order to be compliant with ERAS recommendations please consider the following: restrict the fluid to <8 ml/kg/hr IBW, usually 4-5 ml/kg/hr IBW are sufficient.

Using an infusion pump with 4-5 ml/kg/hr IBW is the easiest approach!

  • Since many anesthesiologists are concerned about the side effects of Hespan, albumin 5% is used in our practice more often than before. It is a valid but relatively costly alternative.
  • Please don’t chase patient’s urine output since healthy kidneys should retain water and salt during “stress”, and not pour urine out!
  • If your patient is hypotensive, check your anesthetic, it may be too deep. Please avoid “relative” or anesthesia induced hypovolemia by keeping your volatile agents low. A BIS-device may help you with that if you are uncomfortable choosing low concentrations of volatile agents.

 

Ventilation:

  • Consider “lung-protective ventilation”
  • Choose patient’s ideal body weight (Predicted Body Weight is more accurate), not the actual weight.
  • Choose low tidal volumes (6-8 ml/kg based on Predicted Body Weight). Ideal body weight is a good estimate and requires less calculation.
  • Increase RR to achieve desired MV if necessary. Mild hypercarbia increases the tissue oxygenation, and is beneficial (hemoglobin dissociation curve)!
  • Use at least 5 cm H2O of PEEP on every ventilated patient.
  • I:E ratio 1:1.5 or higher, if the patient has no significant obstructive lung disease. This ratio may help avoid high AW peak-pressures during pneumoperitoneum; peak-pressure is not the pressure alveoli are exposed to, plateau-pressure is (not measured by our Draeger Ventilator).

 

Recovery room:

  • Standard procedures
  • Please write for fentanyl and dilaudid as needed. With a multimodal pain management the opioid requirements should be low.  TAP-Block if necessary.
  • All patients will be on dilaudid-PCA

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