ERAS (preoperative preparation and postoperative care gynecology)

 Description

ERAS (Enhanced Recovery After Surgery) is an evidence based protocol designed to

improve a faster and better recovery after (bowel) surgery. This protocol has been
adapted for genealogical patients who undergo a (oncological) laparotomy

 Qualification
Nurses, (assistant) gynaecologist

 Purpose

Faster and better recovery after gynaecologic oncologic laparotomy

 Indications
Gynaecological patients who will undergo an oncologic laparotomy

 Contraindication

Emergency surgery.

Patients who can’t have clear liquids for other reasons, for example dysphagia, or low
EMV-score

Patients who feel nauseous and/or are vomiting.

Delayed gastric emptying, ileus, or non-functioning gastrointestinal tract.

 Complications
Unknown.

 Preparation
Pre operative on ward (gynaecologist and nurses):
o Patient receives ERAS brochure during screening on ward.
o Proper instructions by nurse during screening on ward.
o Screening for malnutrition by using the MUST method.
o Screening for distress by using Distress therometer (done by clinic nurse before
hospitalization)
o I.P. no bowel preparation, exceptions are made by doctor.

Day before surgery (nurses)

 If necessary consult by stoma care nurse and decide on placement.
 Normal nutrition.
 Measure and fit oncology patients with compression stockings.
 Instruct patients on how to mobilise post operative and on how to use triflow.
 Start Fraxiparine according to doctor’s instructions.
 Offer patients microlax (if needed).

Procedure
Day of surgery, preoperative (nurses & anaesthesia)
 Until six hours prior to surgery: normal nutrition.
 Until two hours prior to surgery: clear liquids (water, clear juice, concentrate,
non-carbonated soft drinks, coffee/tea (without milk). Patient is stimulated.
 2-3 hours prior to surgery: give patient 400 ml of OK Roosvicee (90 ml Roosvicee
and 310 ml of water) or concentrate (raspberry/orange, 65 ml of concentrate and
335 ml of water).
 Insulin-dependent patients: clear liquids, carbohydrate drinks, check blood
glucose, follow anaesthetist’s insulin instructions.
 If the surgery is after 1 pm: patient can eat a light, non fat meal, until 6 hours
prior to surgery (bread or toast with butter, jam or non-fat meat/cheese and 1
glass of milk.
 1 hour prior to surgery: 1000 mg of Paracetamol on doctor’s orders.
 5000 E heparin natrium (in case patient came in sober on the day of the surgery)
on doctor’s orders. Take with 30 ml of water.
 No slow working pre-medication (Benzodiazepine) with exception of patients who
take sleep medication on a regularly and extreme nervous patients.
 AB according to prescription.
 All oncology patients put on compression stockings
 Cover patients when they’re taken to OR

During surgery (anaesthetics)

 Thoracic epidural anaesthesia on TH. 8-9, if indicated.
 Single antibiotic, 15 minutes prior to incision.
 Don’t give more intravenous fluid than lost during surgery.
 Bair hugger
 Insert naso gastric tube and urinary catheter.

Post operative on day of surgery (anaesthetics and recovery nurses)

 Remove naso gastric tube on recovery.
 Patient has epidural catheter and urinary catheter.
 Intravenous fluid therapy guided by urine output (30ml/hour)

After returning to ward

 Start clear fluid diet
 When drinking clear fluids goes well: start giving fluid food or bread/toast 4 hours
after the surgery.
 Follow nausea and pain protocol carefully.
 Maintain epidural and urinary catheter
 Mobilise patient towards the edge of the bed or into a chair.
 Practice with Triflow.

Day 1 Post operative (nurse and anaesthetics)

  IV will be stopped restart at intake < 1500ml
 Liquid and bread, if that goes well then normal nutrition.
 Note on food record chart that patient is following ERAS protocol and on what
day the patient is post operative.
 Pain medication: epidural and 4 times PCM per os according to doctor’s
prescription and if necessary diclofenac on doctor’s orders.
 Maintain urinary catheter because of epidural.
 Mobilise: wash patient on the edge of the bed, while making the bed, let patient
sit in chair and try to get the patient to get out of bed (two times 30 minutes).
 If patient doesn’t have an epidural, let patient walk a bit.

Day 2 Postoperative
 After anaesthetist decides: stop epidural at 6 and follow the pain protocol.
 Remove epidural catheter by anesthesia.
 Remove IV and urinary catheter 6 hours after stopping epidural.
 Regular diet or diet supplemented with two bottles of nutridrink protein plus (in
the morning and in the afternoon).
 Start magnesium hydroxide 2 times a day 724 mg according to doctor’s orders
and chew gum, until stool is normal.
 Try to get the patient out of bed 3 times a day for 2 hours.
 Wash under the shower or over the sink.

Day 3 Postoperative and beyond

 Extend diet
 Extend mobilisation
 Give discharge instructions
 All patients were pelvic lymph nodes were removed get information and a flyer about
lymphedema
 Make outpatient appointment, if necessary make aftercare appointment (by phone)

Discharge criteria
 Regular diet or diet supplemented with two bottles of nutridrink.
 No fever.
 Good wound healing.
 Correct pain medication
 Independent ADL.
 Discharge conversation with nurse or doctor. In case of post operative constipation,
the patient will receive Laxantia (in consultation with doctor) to use at home. Agree
that patient will contact the ward, doctor or GP if still constipated after two days
after discharge.

Aftercare
 Give patient an overview of the agreements made, patient satisfaction questionnaire
and if necessary prescriptions.
 Alert an oncology nurse for homecare if necessary.

Reporting
 Write down the given care together with the patient’s experiences in EZIS.