Colorectal - Enhanced Recovery After Surgery (ERAS) Pathway

Introduction

You have been chosen to take part in an Enhanced Recovery Programme (ERAS). The programme has input from a whole team (surgeons, anaesthetist, specialist nurses, physiotherapists and dietitian). Its aim is for you to recover from your operation as soon as possible.

This leaflet gives you some information about the progamme and how you can play an active part in your recovery.

After discussing your operation with your surgeon, you will be seen by the Colorectal and the ERAS Nurse specialists. If it is necessary for you to see the stoma nurse this will be discussed also.

The three important parts of this programme are good pain control, for you to be up and about as soon as possible (early mobilisation) and early introduction of food and drinks.

Prior to admission

Bowel preparation

If it is necessary for you to have bowel preparation (laxatives) this will be discussed with you by your surgeon, colorectal and ERAS nurse specialists. This may be enemas and or medication to drink.

Discharge planning

It is helpful if you can discuss with your relatives, carers and friends whether you think you would need social service help on discharge for example home help, meals on wheels. This will be discussed during your first meeting with the ERAS specialist nurse.

Once we know what help you will need at home, we are then able to start planning for your discharge which makes the process as straight forward as possible. This will be discussed with you by the ward staff on admission. (separate information leaflet Leaving Hospital).

Food and Drink

Before coming into hospital please continue to eat and drink normally

• You may be given supplement drinks (ensures) please take these as directed
• You may also be given 3 sachets of Pre-Load, an energy drink to take before your operation. These drinks give you the energy you will require to help recover from your operation

Drips and tubes

Whilst asleep it is usually necessary to put a tube into your bladder (catheter) as part of your operation. This will enable the staff to monitor how much fluid you need. It may also be necessary to put a drip into your wrist and a drip into a vein in your neck to monitor you during and after your operation. These will be removed as soon as possible after your surgery. Your anaesthetist will discuss this with you before your operation.

Pain control

You will be seen by an anaesthetist before your operation who will discuss pain relief with you, this may be an epidural, pain relief given continuously through a tube inserted in your back. Or patient controlled analgesia (PCA) pain relief you control yourself. (There are separate leaflets that explain these 2 forms of pain relief in more detail).

After your operation

Pain Control

Good and effective pain control is essential to a quick recovery. If your pain is well controlled you can walk as early as the same day as your operation, deep breathe, eat and drink and feel relaxed. It will help you sleep well and ensure you are rested.

If your pain control is not effective and you are in discomfort/ pain it is essential that you speak to the nurse looking after you as soon as possible as you may need to be seen by the pain team.

While you are asleep your surgeon may put some local anaesthetic around your tummy wound. This can help to reduce your discomfort when you wake up.

Mobilisation/Physiotherapy

Early mobilisation (i.e. getting out of bed and walking around) is a very important part of your recovery. Most patients will get up the day of, or the day after their operation. You will be encouraged to sit out in a chair and walk short distances at least 4 times a day, with help from the nursing staff and the physiotherapists.

Having an operation has an effect on your breathing and your circulation. The physiotherapist will see you if required and will be able to give you help and advice. The following exercises will help to reduce complications and speed your recovery.

1.    Deep breathing exercises

Following your operation, you tend to breathe more shallowly and not expand your lungs at the bottom. These exercises help to improve your lung movement and clear phlegm off your chest.  Start these exercises as soon as you wake up, and continue hourly whilst awake, until you are up and about again.

Sit in a comfortable position with your back well supported (upright in bed or in a chair), place your hand on the upper part of your stomach.

Relax your shoulders

• Take a slow deep breath in through your nose, concentrating on expanding the lower part of your chest
• Hold the breath for a count of 3, then slowly breathe out completely, repeat 3 or 4 times

2.    Huffing

Coughing can be uncomfortable and tiring. It has been found that ‘huffing’ helps to move phlegm in preparation for coughing.

• Take a small breath in
• Open your mouth wide and squeeze the air forcefully out of your lungs as quickly as possible (as if steaming up a mirror)
• Your stomach muscles should contract but your throat muscles should not tighten
• The huff must be long enough to move phlegm from the airways

3.    Coughing

Adequate pain relief and the correct coughing technique are essential to clear phlegm comfortably and effectively. Once phlegm has been loosened by ‘huffing’ try a supported cough.

• Position yourself either sitting in a chair, on the edge of the bed, or lying in bed with both knees bent up, to relieve the stretch on your tummy, place hands or pillow over your stomach
• Take a deep breath in and as you cough squeeze your hands in over your stomach in order to support i

Circulatory exercises

Good circulation in your legs helps to prevent deep vein thrombosis (DVT) or blood clots. You will be given a pair of special support stockings (TED stockings) to wear the morning you go to theatre. You will be encouraged to wear them throughout your hospital stay. These help push blood back to your heart.

Also remember not to cross your legs or ankles as this can make the circulation more sluggish.

• Ankle circling involves moving the feet clockwise and anti- clockwise in circles - Repeat 10 times
• Keeping your legs straight bend your feet firmly up and down at the ankles - Repeat 10 times

Keeping your legs outstretched, press the back of your knees down into the bed and tighten your thigh muscles. Hold for a count of 3 and relax - Repeat 10 times

It would be helpful to practise these exercises before you come into hospital

Food and Drink

You will be offered food and drink as directed by your surgeon, this may be as early as the same day as your operation.

• You will also be encouraged to take supplement drinks ensures/ enlive, 3 per day as well as a normal diet
• By eating and taking these drinks your body will receive the extra nourishment it needs to help heal your wounds and help your recovery

High Dependency Unit (HDU)

It may be necessary for you to be admitted to HDU after your operation. A separate leaflet is available which will provide you with information regarding the Unit.

Returning to work

You will be able to return to work within 6 to 12 weeks depending on your particular operation and your job. Please discuss this with your surgeon before you are admitted to hospital.

Further information about your discharge will be given to you on the ward following your operation.

If you have any other questions, please ask.

Contact details

ERAS nurse specialist
Sister Rachel Meskell/Sister Samantha White via hospital switchboard, telephone 0161 789 7373 ask for bleep 3443.

Colorectal nurse specialists
Telephone: 0161 206 1249 where there is an answer machine.