Enhanced Recovery After Surgery (ERAS) - Salford Royal

Nutritional care is a key focus of the ERAS (enhanced recovery after surgery) pathway before and after surgical treatment. The Dietitian will provide nutrition support before and after surgery to make sure you are nutritionally optimised at every stage.  

Good nutrition is essential before and after surgery to help prevent infections, promote wound healing, increase muscle strength for mobilising/physiotherapy, assist with symptom management and to support a quicker recovery phase. 

A hospital ward patient bay. A patient sitting in a chair next to bed. A nurse in uniform and plastic apron sitting next to her. A tray of food on a table. Nursing care. Mealtime. Nutrition and hospital catering.

Who are Dietitians and what do they do?

Dietitians specialise in providing treatment to patients with a range of conditions and work closely with other members of the multidisciplinary team in overseeing nutritional care. Nutritional care is a key focus of the ERAS (enhanced recovery after surgery) pathway before and after surgical treatment. 

The Dietitian will advise on pre-op nutrition and how you can optimise your nutritional status in advance of surgery. They will provide post-operative support, assisting you to meet your nutritional requirements and following surgery as well as supporting with symptom management.

Why is nutrition important in peri-op phase?

Surgery is compared to running a marathon. The same physiological stress put on the body following surgery can be compared with running a marathon. In the same way you would prepare for a marathon, we have to ensure your body is prepared for surgery in the same way.

Why is nutrition important?

• To prevent infections
• Recovery and wound healing
• Maintaining strength for mobilisation and physio
• Quicker recovery, discharge home quicker

How much fluid should I drink each day?

Good fluid intake is important to make sure the body functions efficiently and to avoid dehydration. The Eatwell Guide says we should drink 6 to 8 glasses of fluid a day. Water, milk and sugar-free drinks, including tea and coffee, all count.

Read the BDA fluid food factsheet

How much fibre should I have in my diet?

There is a general recommendation of 30g fibre each day for the general population.  Fibre is found in plant foods such a fruit, vegetables and wholegrain starchy carbohydrates.  It is important for bowel health and also to reduce your risks of chronic diseases such as heart disease and type 2 diabetes. Your personal requirements for fibre may however be lower than this if you have been advised to follow a low fibre diet prior to or after your surgery.  If you have any questions regarding your fibre requirements, please contact your Dietitian or Clinical Nurse Specialist for further advice.

Why do I need protein in my diet?

Protein is found in meat, fish, eggs, dairy products, nuts, beans,pulses, soya tofu and .  You should aim to include protein rich foods at two meals per day.  Protein provides the building blocks for growth and repair in your body.  It builds muscles and is required to heal after an operation.  Eating a good amount of protein in your diet is important prior to and after your operation to promote your recovery.  A palm sized portion of meat or fish is considered to be an adequate amount of protein for a meal. Three heaped tablespoons of beans, two eggs or two teaspoons of peanut butter provide a portion from meat-free sources.

Carbohydrate loading

Immediately prior to surgery, we recommend carbohydrate-loading through specialised oral supplements. The aim of taking high carbohydrate supplement drinks is to load the body with energy prior to surgery, similar to marathon runners taking a large carbohydrate meal the night before a race. 

Carbohydrate loading helps the metabolism to continue to tick over, reducing surgical stress, promoting recovery and can help in reducing post-operative complications.  Carbohydrate drinks are usually taken the night before surgery and/or on the morning of surgery.  

Studies have shown that these drinks are safe to use in non-insulin dependent diabetes, when blood sugars are monitored in the hospital where they can be treated if become raised.  If you have diabetes, you will therefore be asked only to take the morning dose of the preop carbohydrate loading drink.

Post-operative nutrition

Everyone begins eating and drinking at different stages - some patient’s may be eating within 24 hours after their operation whereas other patient’s may not eat for a few days.

Some patient’s may have a feeding tube placed before or during their operation. If you have a feeding tube you will be referred to the dietitian and specialist nurses for support with your tube and feed.

Recovering from surgery can also be compared to recovery from a marathon. Good nutrition post-surgery is essential in order to promote good recovery so you can recover quicker and go home promptly.

Nutrition is important after your operation to promote recovery and wound healing. Your body has gone through a huge physiological stress, therefore it is essential that you promote recovery and wound healing and for mobilisation and physio.

You may have supplements prescribed before or after your operation to help support your intake. Oral nutrition supplements are designed to provide you with extra calories and protein. They come in a variety of forms to suit everyone individually e.g. milkshake style, juices, yoghurts, dessert, and savoury. If you have been prescribed supplements, we encourage you to take these as soon as you are able. 

The following is a direct transcript from the above video, and has been split into each slide that you see.

Introduction and Welcome

Hi, and welcome to surgery school. I’m Robbie and I work as part of the physiotherapy team in Salford and I’ll be presenting the first part of the presentation. This is a generic overview on how best to prepare for your surgery.

General Wellbeing

If you smoke then stopping is the single most important thing you can do to improve your health.

Your consultant may consider delaying surgery if you are still smoking before for the operation. Also reducing alcohol intake is very important. We can help support you at Salford Royal or through your GP. You can ask your specialist nurse if you would like to be referred for any help.

Surgery is a body stressor

As it says on this slide, surgery is a body stressor but we can help prepare you for it. Surgery puts extra demand on the body, not just during an operation but in the days and weeks afterwards and during your recovery.

If the body can't keep up with this extra demand then you are more likely to have complications.

Complications not only make you feel unwell but will keep you in hospital for longer. So, what can we do together to make your surgery safer and smoother?

The 6 components of ERAS+

The next slide is all about ERAS+ which surgery school is a part of.

ERAS+ stands for Enhanced Recovery After Surgery and is a programme which runs throughout Greater Manchester.

ERAS+ has several components which are:

• Prehabilitation. Which is patients getting fitter before surgery
• Surgery school. Giving the patients the correct information so that they are well informed before they come in to surgery.

All about what to expect about your hospital stay.

• Chest training. This is getting your lungs fitter before you come in to surgery
• Rehabilitation after surgery. When you are discharged from hospital.
• Outcomes. This is about gathering the best data possible from patients so that we can improve the service for the next group of patients who come in to surgery.

Does ERAS+ work?

Chest infections are common after major surgery. Particularly, surgery to the abdomen. This graph shows that the ERAS+ has helped to half the number of chest infections after major surgery at Manchester Royal Infirmary. So we know that implementing this programme really works.

The program is now been rolled out to all the hospitals across Greater Manchester.

So as you can see the next slide has four sections and I'll be going to each one in more detail in the next few slides.

Activity muscle training - as we spoke about surgery is a big stressor for the body and we need to get you as fit as possible. 

Chest training - its important to get your lungs fit and ready for surgery.

Nutrition - your body is getting ready for surgery and you need to eat well and we can help advise you have to do that.

Also family and friends - you will benefit good support network to help you prepare and recover after your surgery.

Nutrition

Hi there my name is Rachel and I'm part of the dietitians team and I'm going to be talking to you about good nutrition before and after your surgery.

In the same way you are prepared for a marathon nutritionally we have to ensure the body is prepared for surgery in the same way.

Why is nutrition important? 

• To prevent infections from recovery
• Improved wound healing
• For maintaining strength for transfers and physiotherapy as an in-patient. 
• For a quicker recovery so you can get home quicker.  

The Eatwell Guide

The main nutritional guidance before surgery is to focus on eating a balanced diet. The Eatwell guide is a policy to define government recommendations on eating healthily and achieving a balanced diet. The Eatwell guide in front of you shows you how much of what you eat should come from which feed group. 

The first food group on the right hand side, which is one of the largest food groups, and has a yellow background, this is a carbohydrate food group. This should be your main source of energy throughout the day and make up about a third of our daily intake. Meals should be based on potatoes, bread, rice,  pasta and other starchy carbohydrates.

The second largest group on the left hand side with a green background, this is the fruit and vegetable food group. This should also make up about a third of your daily intake. We should aim for around five a day of different portions of fruit and vegetables. Frozen, tinned and fresh fruit and vegetables or count towards this intake. A portion of fruit and vegetables in approximately 80 grams which is usually around the side of the palm of your hand. 

The next food group is the protein food group which is has the pink background.  We should eat some beans, pulses, fish, eggs, meat and other protein. Vegetarian sources of protein include Quorn and tofu. Pulses such as beans, peas and lentils a good alternative to meat because they are  lower in fat and high in fibre and protein. 

The next food group is the dairy and dairy alternative food group which has the blue background.  We should be aiming for three different portions a day.  Milk, cheese, yoghurt and fromage frais are good sources of protein and some vitamins and they are an important source of calcium, which helps keep our bones strong.  Milk alternatives such as soya rice and oat milk. If you're having an alternative make sure they are enriched with calcium so you are getting the full benefit. 

The final group I'm going to talk about is the fat, sugar and alternatives. And as you can see this food group isn't actually included on the guide, it's just in the left-hand corner. So this food group includes chocolate, cake, biscuits sugary soft drinks, butter gee and ice cream. So these are not necessarily needed in our diet but they should be eating less often and smaller amounts. Some patients may have been advised to have higher quantities of high-fat or hi sugar food if they are fortifying their diet. This will have been advised by a dietitian and it is usually for patients who are struggling to meet their nutritional requirements and are loosing weight.

Timing

I'm now going to talk about nutrition at different stages of your operation. This includes before your operation, the day of your operation and then after your operation.  

Firstly it's really important to try and maintain your weight before your operation. This is to ensure your body is as fit as  possible in preparation for your surgery. The day before your operation we recommend technique called carbohydrate loading. Most people prepare for a marathon by carbohydrate loading the night before. It means taking additional carbohydrate food and drink to ensure they have a good store of energy in advance of the race. We strongly recommend carbohydrate loading the evening before your operation.   We should be aiming for 100 g of carbohydrates the night before. The best to achieve this is to have a carbohydrate rich meal followed by a carbohydrate rich snack for super. Examples of rich carbohydrate meals could include pasta, potato spaghetti or cereal. And example is a rich carbohydrate snack but you could have for super include; toast that you could have with with milk banana and a yoghurt or a glass of milk and cookies.  

Some patients would've been given a sachet of preload at a pre-op appointment to take on the day of the operation. Preload is a carbohydrate drink taken on the day of your operation to provide your body with energy during a time when you will not be eating. If you have been given a sachet of  preload this would have been given to you by a specialist nurse and they will tell you how to take your preload.  If you have any questions or queries relating to your pre-load or you have not yet received it please speak to your specialist nurse. 

You may have been prescribed nutritional supplements before or after your operation to help support your intake. Oral nutrition supplements are designed to provide you with extra calories and protein. They come in a variety of forms to suit everyone individually, for example milkshake style drinks, juices, yoghurt and savoury.  If you have been prescribed supplements we encourage you to take them as soon as you are able. 

Nutrition Summary

Finally to summarise: nutrition is important after your operation to ensure you recover quickly as possible so you can go home as soon as possible. Good nutrition is essential after your operation to ensure you maintain strength and are able to participate in physiotherapy as an inpatient.

Activity and Muscle Strengthening

Hi my name is Ebie. I'm one of them one of the physiotherapy team and I'm going to talk to you about muscle strengthening. There are a few types of activity you can safely partake in which form part of active daily living. You just need to increase the frequency of these activities.

They are:

• Walking to the local shop and carrying your shopping bags.
• Walking the dog whether it’s your dog a family dog or a neighbours dog.
• Climbing the stairs instead of taking the lift. 
• Avoiding sitting down for a long periods of time.
• Completing activities when standing such as housework. This would include ironing, cooking, vacuuming and washing up and doing some laundry. Also playing with your children or grandchildren, gardening, dancing and socialising, cycling and swimming.
• The benefits of joining group actives are numerous such as; meeting new people which is good for psychological standpoint of view. Also you can take someone with you for support.  These activities are yoga Pilates and Zumba.

Macmillan Move More

So in the next slide you can see this chart that you can find in Macmillan website or in Macmillan ‘move more’ booklet and it tells you some activities to do to be active. 

150 minutes of moderate activity in a week.   

These activities include walking gardening or swimming. 

Or you can do 75 minutes of vigorous activity a week.   

These activities include running, doing sport and climbing up and down and down the stairs. 

To build strength, exercise twice a week by going to the gym.  

This would include aerobic exercises and carrying your bags. 

Improve your balance by practicing two days a week of dancing, tai chi, and bowling. 

Also in the red box it tells you to sit less whilst watching TV, to sit less on the sofa and sit less using your computer. 

It is also important to do activities that improve muscle strength. This is needed to get up and out of bed soon after your surgery. These following exercise that anyone should be able to complete.  

You should aim to do the following exercises once a day three times a week: 

- Arm curls. Stand or sit in a chair with your arms by your side with your palms facing forward and bend your elbow. If you find this easy you could doing exercise holding a tin of food or water bottle or a weight to make it more difficult.  Aim to repeat this five times on each hand.

- Arm raises. Again sit on a chair or stand. Lift both arms together and above your head and then out in the front of you. If you find it easy you could do the exercise holding a tin of food or water or a dumbbells. Aim to repeat this exercise five times.

- Sit to stand from a chair. Put your arms across your chest and stand up from a chair and then sit back down again slowly. If you feel too unsteady then don't cross your arm and a likely use your arms to push up from the chair. Aim to repeat this exercise about five times. 

- Mini squats. Whilst standing hold onto the back of a chair or firm surface. Keep your feet hip width apart, slowly bend your knees as far as you feel comfortable. Keep your back as straight as possible, hold for two seconds and then straighten your knees. Squeeze your bottom muscles and thigh muscles as you do.  Aim to repeat this exercise for five times.

- Marching on the spot. Ideally stand, but you can complete this in sitting if you feel unsteady.  March on the spot for 30 seconds, rest for 30 seconds. If you find this easy bring your knees up higher whilst you are marching. You can do this whilst you are waiting for the kettle to boil.  Aim to repeat this exercise for three times.  

Once you are able to manage these exercises more easily then you can gradually increase the number of times and the time you spend doing these exercises. If you feel you have a specific need then speak to an expert for advice. 

GM Active

Depending on your type of surgery your specialist nurse may refer you to the GM active team. This is the first scheme of its kind in the UK and we’re very lucky to have access to it in Greater Manchester. This is a free scheme running at your local gym which will help you get fit before your surgery.  

The exercise specialists will asses you and tailor a plan of how to exercise safety. They will see you before your surgery which we call prehabilitation, and when you are discharged for your rehabilitation.  

The team at PreHab for Cancer will work closely with you to support you before and after your surgery, building an activity plan for you to follow. They will help monitor your nutrition and general wellbeing. 

The day you are admitted to hospital

If you arrive at the surgical admissions lounge at 7am you’ll be changed into a hospital gown, have TED stockings put on your legs, you’ll be meeting your anaesthetist and from surgical admissions lounge you’ll go directly to theatre.  

Your specialist nurse will go through all these details in more depth during your one to one. 

Pack your bag

For your first night in hospital you’ll only need to bring a small bag with a few things to the surgical admissions lounge.  

Firstly your incentive spirometer a small device which helps with your breathing. We’ll learn a little bit more about this in the following slides.  

Secondly a toothbrush and toothpaste and finally some basic footwear. Ideally slippers with support around the back of the foot which are more secure when you are mobilising in the hospital.

Brushing your teeth

Good oral care reduces risk of lung complications after surgery and improves your overall general health. Bugs and bacteria that live in your mouth can travel into your chest during surgery which can contribute to chest infections. Reduce this risk by making sure that your mouth care is effective in the time before and after surgery.  

We want you to concentrate on optimal dental care leading up to your surgery by focusing on brushing your teeth twice a day for two minutes. Make sure your brush slides across your teeth and along your gum line especially on the inside surfaces next to your tongue and on the roof of your mouth. 

Brush your teeth or dentures at least twice a day, last thing at night and on one other occasion.  Use a small headed soft of medium toothbrush, replace your toothbrush every two to three months or sooner if the bristles start to look a bit like the one in the picture. Use a pea size amount of fluoride toothpaste when brushing your teeth.

Chest training and iCough

After a general anaesthetic and surgery our chest and lungs are prone to problems. Chest training aims to strengthen your breathing muscles before and after surgery to help reduce chest problems. 

The ERAS+ programme incorporates iCough. So what does iCough mean? Incentive spirometer exercises, you’ll see a short video on this in the next slide.

Coughing and deep breathing, this is so we can help clear our lungs. Good oral care, as we discussed in the last couple of slides oral hygiene is vitally important to avoid chest infections

Understanding iCough

Get out of bed. Depending on which surgery you are having a physio will come and see you on the morning after your surgery to get you out of bed, walk you around the bay and check your chest and make sure there aren’t any problems with your breathing. If you don’t need the support of a physio the nursing staff can help you with your mobility until you can continue mobilising independently. We get people out of bed the next day after surgery to stop people getting chest infections and to stop muscle wastage. You can think about this as  you exercise in hospital and any exercise before surgery will make this easier
Head of bed elevated. When you are in hospital we would like you to have the bed elevated to thirty degrees but ideally we’d like you to be sat out in the chair. This is to make your breathing easier and can help with any pain relief medication such as epidurals

Incentive spirometer video

An incentive spirometer is a small device that encourages you to take a deep breath by inhaling through a tube.  

Why is this so important?  

Well before surgery it increased your lung capacity it trains you to be able to take a deep breath and it prepares your lungs for surgery. After surgery it will help re-open the bottom of the lungs. It will encourage the movement of secretions or phlegm out of your lungs so you can cough it up. It reduces the risk of a chest infection and it may help to speed your recovery and reduce the length of your hospital stay.

Sitting in an upright position fully exhale all of the air from your lungs. Place your lips around the mouthpiece and ensure a good seal and that the tube is connected properly. Slowly and controlled take a deep breath in. The small yellow ball should hover in the smiley face region. Maintain a slow deep breath in for as long as you can. The mark on the right indicates how big a breath you are taking. The higher the better. Complete three cycles of three breaths each ensuring you rest in between. After using your incentive spirometer make sure you cough and clear and phlegm or secretions.  

Before surgery aim to complete this at least four times a day in order to train your lungs in preparation for surgery.  

After surgery complete this hourly until your mobility is back to normal.  

Your physio will provide you with more guidance on this. Please remember to bring your incentive spirometer in on your day of surgery. 

After your surgery

So what do we expect from you post surgery?  

Start using your incentive spirometer again, the physiotherapist may visit you during your stay to encourage and check your technique with your deep breathing exercises such as huffing, coughing and using the incentive spirometer. You will be expected to continue this every hour that you are awake. Continue using your usual mouth care twice a day just as you have done at home.  

As soon as possible we will get you in your own clothes to make you feel back to normal and less like a patient, something we call PJ paralysis. Get moving around. You may need assistance at first but as you recover you should do more by yourself and prepare to manage at home again.  

Getting out of bed as early as possible is important to reduce the risk of breathing problems and clots on the legs or lungs. So you may be tired after your surgery but it is vitally important to mobilise you out of bed as soon as possible.  

The physios or the nursing staff will help you with this exercise and we will mobilise you to a patient chair in your bed area and if you are doing well we will go for a short walk away from the bed area. You may be attached to various lines that monitor you or deliver medication to start with so you may need help from the physiotherapy or nursing staff at first. You can think of this as your exercise whilst you’re in hospital and any exercise before surgery will make this a lot easier.  

So why do we do this? The aim is to return you to a normal level of independence as soon as possible and we’d look to progress you as quickly and safely to get back to this point.  We complete all these exercises to avoid you getting a chest infection.  Mobilising from the bed to the chair and walking does many things.  It keeps your muscle strength whilst you are in hospital, helps you take deep breaths whilst walking and clears your chest and reduces infection risk.  Also if you’ve been prescribed nutritional supplements for example ensure plus milkshake then start to sip these slowly after your surgery.

Preparing for discharge

I’m sure no-one likes to be in hospital and though we’d like to get you discharged as soon as possible we have to make sure that you are safe enough to be discharged. So you will allowed to go home when the doctors are happy that you are medically well enough to leave hospital and all the health professionals who have been involved in your care have completed their assessments and treatment.  

If you are independent before you came into hospital by this time you should be able to get in and out of a chair and a bed comfortably. Be able to get yourself washed, dressed and back wearing your own clothes on the ward. Be able to mobile around the ward safely and be able to climb stairs if you have them at home.  If you have been in hospital for a while and you or the physiotherapist have any concerns about you being able to climb stairs then they may suggest that you practice them before you go home.

Once you go home remember everything you have learnt about preparing for surgery and keep up the good work. You may need a little help from family and friends and first and there may be ups and downs but you should aim to gradually regain your strength and independence. Family members - it is important to support your relative but be sure to encourage their independence too. 

To summarise

• Get active to help prepare you body for the strain of surgery
• Stop smoking or reduce alcohol intake
• Good nutrition will help you remain active and promote healing
• Remember the steps of ERAS+
• Practice your incentive spirometer before surgery and make sure you bring it with you on the day of surgery.
• After surgery we will be mobilising you as much as possible and continue your rehab after you are discharged to help you recover. 

Thanks for listening to surgery school and I hope you found it very informative. If possible you could complete a short questionnaire by scanning the QR code with your smart phone, which is located in the bottom right hand corner. This will help us improve our surgery school for the next lot of patients. Thank you.