I. A Better Journey for Patients, a Better Deal for the NHS: The Successful Implementation of an Enhanced Recovery Program After Renal Transplant Surgery
- Briefly summarise this article highlighting the principal elements of enhanced recovery in renal transplant recipients.
- What is the level of evidence provided by this article?
- How would you implement enhanced recovery in your workplace?
Well-designed non randomized controlled trials of level 3 evidence
Summary of the article: The principal elements of enhanced recovery in renal transplant recipients.
-The idea of enhanced recovery (ER) centers on a recovery system to reduce post operative pain and to accelerate recovery.
-264 renal transplant patients were involved in the study; 135 patients underwent ER program compared with 151 patients who had traditional recovery (all diabetic patients were excluded).
-Intraoperative care included:
· Implementation of trans-esophageal Doppler to achieve the best fluid balance and to avoid the use of central lines (which were only used when inotropes were required or in cases of rATG) induction.
· Intrathecal diamorphine combined with US guided transversus abdominis plane block were applied to enhance the post-operative analgesia in the 1st 24 hours and to minimize PCA.
-Post-operative care included:
· Early mobilization was encouraged from the first postoperative day
· Free oral intake few hours after the operation aiming for early discontinuation of IV fluids.
· Oral analgesia were also commenced after discontinuation of the PCA morphine on the first postoperative day.
· Urinary catheters were removed 2 to 6 days after transplant.
· Wound drains were removed within the first 48 hours of surgery unless productive.
-In the current environment of shortage of health care workers, ER improves the quality of care of renal transplant patients and allow other critically ill patients who need more care to be looked after by reallocating the nursing and medical personnel.
This is the retrospective study with level 3 evidence addressing the applicability of the ER principle in renal transplant to assess the changes in the quality of patient care and patient satisfaction.
286 consecutive renal transplant patients were recruited. Of these, 135 patients went through the enhanced recovery program and 151 patients had traditional recovery.
patient-controlled analgesia requirement for morphine was significantly reduced in the enhanced recovery versus traditional recovery group (median of 9.5 vs 47 mg; P < .001).
The length of stay was significantly reduced for living-donor (median 5 vs 7 days; P < .001) and for deceased-donor transplant recipients (median 5 vs 8.5 days; P< .001) with enhanced recovery versus recipients who had traditional recovery.
Implementing enhanced recovery saves £2160 per living-donor transplant and £3078 per deceased-donor transplant. In the enhanced recovery group, readmission within 10 days after transplant was 5%.
In conclusion, enhanced recovery benefits both types of renal transplant (living and deceased grafts) procedures, with excellent patient satisfaction and reduction of hospital length of stay.
Enhanced recovery in elective surgery is a technique which was firstly implemented as a rehabilitation program, with its principles centered on a multimodal recovery pathway to reduce operative pain, accelerate recovery and to improve patients outcome. It benefits both patients and staff members. It depends on patients as active participants in their own recovery process.
It ensures that patients receive evidence based care at the right time.
Principles of enhanced recovery used in the study
1. Patient education and discharge planning were commenced on admission
2. Preoperatively, prolonged Preoperative fasting was avoided by carbohydrate loading.
The patient received 4 CHO drinks on the day of admission and 2 CHO drinks on the morning of surgery with no overnight fasting . The last CHO was given 2 hours before transplant.
3. Intaoperatively, goal directed fluid management was aided by transesophageal Doppler to avoid central line insertion. Intrathecal diamorphine and ultrasonography guided transverse abdominis plane blocks were used to achieve adequate analgesia.
4. Postoperatively, oral intake was consumed a few hours after the operation to allow discontinuation of IV fluids, laxatives and oral analgesia were commenced after the discontinuation of the PCA morphine, early mobility was encouraged from the first day, urinary catheter was removed 2 to 6 days after transplantation and wound drains were removed within the first 48 hours after surgery unless it was productive.
The results of enhanced recovery versus traditional recovery
The postoperative patient controlled analgesia requirement for morphine was significantly reduced in the enhanced recovery.
The length of hospital stay was significantly reduced in the enhanced recovery.
Implementing enhanced recovery saves £2160 per living donor transplant and £3078 per deceased donor transplant.
Level of evidence: 3
The enhanced recovery program is a multidisciplinary approach to improve patient care, reduce the workload on the medical staff and reduce the cost of treatment. This involves several modalities enhanced by patient education, counseling, early oral intake and mobility to improve the recovery of donors and recipients. This study comprised the recovery of 286 kidney transplant patients: 135 had enhanced recovery program (60 living-donor transplants and 75 deceased-donor transplants) and 151 had traditional recovery.
The enhanced recovery patients had lesser morphine requirement, lesser length of stay than the traditional recovery .the enhanced recovery :
1-saves £2160 per living-donor transplant and £3078 per deceased-donor transplant.
2- reduced readmission within 10 days after transplant .
3- reduced PCA morphine requirements
4- excellent patient satisfaction
level of evidence is 3
This can be applied in low income country like Sudan. The measures are easy to apply but we need to improve patient doctor communication which is difficult due to th large number of patients and little number of doctors.
There is no formally agreed on definition for enhanced recovery. The same principle has been described under different headings including “fast track” and “accelerated rehabilitation.
There was a wrong belief among renal transplant clinicians that the principle of ER would be difficult to implement in chronic renal failure patients undergoing renal transplant. These patients are typically American Society of Anesthesiologists grade III with many comorbidities. At end-stage renal disease (ESRD), dialysis patients have 8 times the mortality rate of their age-matched counterparts in the general population, with cardiovascular causes accounting for more than 50% of deaths
Postoperative care of renal transplant patients is not straightforward. Immunosuppression increases the risk of infection and delays wound healing. If the kidney does not function right away, dialysis is required. In addition, patients may also need a kidney biopsy to exclude rejection of the trans planted kidney. This necessitates prolonged hospital stays or readmission. Perioperative fluid manage ment is also challenging, especially in anuric patients, given the preexisting comorbidities mentioned above.
This is the first published report addressing the applicability of the ER principle in renal transplant. Our ER program is a multidisciplinary, evidencebased approach that benefits both patients by improving their care and also the NHS by reducing the workload on the medical staff. In addition, there is a reduction in the cost of treatment. We found reduced PCA morphine requirements, reduced lengths of hospital stay, and reduced readmission rates in association with the excellent patient satisfaction.
The various modalities that we used are not new to medical practice; however, when delivered together in a structured, well-designed care pathway, good results are achieved. Carbohydrate loading is known to reduce the postoperative catabolic phase and can enhance healing.However, this has never been tested in ESRD patients. We believe it is valuable in enhancing recovery in ESRD patients and may counteract the postoperative hyperkaliemia due to its CHO content.
The National Institute for Health and Care Excellence Guidelines in 2012 recommended the use of transesophageal Doppler to monitor fluid balance in patients who had a major operation. Central venous pressure monitoring can be inaccurate and even inappropriate to guide the fluid therapy. The central venous pressure does not always give an accurate indication of the fluid status of the patient nor does it give a reliable response to fluid challenges. We relied on the clinical assessment of the patient (fluid input and output and vital signs, mainly mean arterial pressure) with daily weight measurements to gauge postoperative fluid therapy. In ER patients, the central line was used only as an access for inotropic treatment in the intensive care unit setting or for administration of certain induction agents (eg, thymoglobulin).
Finally, nursing care is hugely important, as this program relies on nursing staff to implement and support the daily milestones, mobilization, and discharge. This may be best implemented in the form of structured care pathways. This role has expanded in our unit to involve the preoperative education and postdischarge follow-up. We have to emphasize that ER does not only improve the quality of care of renal transplant patients but also provides other patients with advantages by reallocating the nursing and medical staff to look after critically ill patients in the current National Health Service environment of shortage of health care workers.
Level 2 evidence
Aim of the study: to assess the impact of enhanced recovery/fast track or accelerated rehabilitation on the post-operative recovery of kidney transplant recipients.
Study design : 286 patients;135 patients renal transplant recipients having ER protocol vs 151 patients with conventional recovery.
Basic items in ER protocol include:
– Active patient involvement in the recovery process.
– Patient education.
– No overnight fasting, carbohydrate loading on day of admission.
– Transesophageal doppler to asses fluid status.
– Intra-thecal diamorphine or transverse abdominal plane block analgesia.
-Trial to stop IV fluids at the end of first day by initiating free fluid intake early post-operatively.
– Early removal of drains and urinary catheter.
Limitations of study:
Historical control group.
– Morphine data was not known for all patients.
– Carbohydrate drinks were not given to all non-diabetics.
– Survey of satisfaction was not fulfilled by all patients.
Level 3: no randomization with historical control group.
Enhanced recovery is implemented through multidisciplinary team including surgeons, nephrologists ,intensivists and dieticians.
A Better Journey for Patients, a Better Deal for the NHS: The Successful Implementation of an Enhanced Recovery Program After Renal Transplant Surgery
The goal of the ER program is to enhance patient outcomes and hasten a patient’s post-operative recovery. Patients and employees gain from it. The program places a strong emphasis on ensuring that patients take an active role in their own healing. Additionally, it attempts to guarantee that patients always get the appropriate, evidence-based care. Improvements in patient care ultimately result in shorter hospital stays (this length is reduced by default).
Patients with kidney transplants require complex postoperative care. Immunosuppression slows wound healing and raises the risk of infection. Dialysis is necessary if the kidney does not immediately begin to function. Patients could also require a kidney biopsy to rule out kidney transplant rejection. Long hospital stays or readmission are therefore necessary. Given the aforementioned pre-existing comorbidities, managing perioperative fluid is very difficult, particularly in anuric individuals.
In this service review, we applied several techniques for pain management and fluid management, complemented by patient education, counseling, early oral intake resumement, and early mobility to improve the recovery of kidney transplant patients who received living or deceased donors.
Both living and deceased graft renal transplant procedures benefit from improved recovery, which results in good patient satisfaction and a shorter hospital stay.
Materials and Methods:
We analyzed 264 consecutive renal transplant patients. Of these, 135 patients (60 living-donor transplants and 75 deceased-donor transplants) went through the ER program compared with 151 patients (85 living-donor transplants and 66 deceased-donor transplants) who had traditional recovery.
For living- donor recipients, received carbohydrate (CHO) loading
For deceased-donor recipients, received 2 CHO drinks while waiting for cross-match results.
To establish a sufficient fluid balance and prevent the need for central lines, intraoperative anesthetic care included goal-directed fluid therapy utilizing transesophageal Doppler. Only when inotropic support was required or when thymoglobulin induction, an immunosuppressive medication that needs intravenous access for delivery, was necessary were central lines used. During the first 24 hours following surgery, intrathecal diamorphine and an ultrasonography-guided transversus abdominis plane were used to reduce the amount of systemic morphine (1 mg/mL) used for patient-controlled analgesia (PCA) and to enhance postoperative analgesia.
After a few hours of free oral intake following surgery, intravenous fluid replenishment could be stopped within the first 24 hours. From the first postoperative day, early mobilization was recommended, allowing patients to sit in a chair for two hours. On the following postoperative days, mobility was gradually enhanced.
On the first postoperative day, laxatives and oral analgesia were also started after PCA morphine was stopped. After a donation, urinary catheters were removed 2 to 6 days later (average of 4 days). If wound drains were utilized, they were taken out within 48 hours of operation, unless they were effective (> 100 mL/24 h). Early mobilization and ongoing patient education were made possible by this.
Comparisons were made between successive historical controls extrapolated from our database who did not have any of the aforementioned ER features and the length of hospital stay, morphine requirements, and oral analgesia requirements.
None of the patients in the conventional recovery group received TAP blocks, ID, goal-directed fluid therapy, or CHO beverages.
Morphine patient-controlled analgesia was also stopped 24 hours following surgery. On day 5 or occasionally later, the urine catheter in the control group was withdrawn. Regarding the surgical drain’s removal, no strategy was decided upon. Additionally, there was no official schedule for intended discharge or early mobilization.
Results:
Between the ER group and the conventional recovery group, there were no changes in the patient characteristics of age, sex, type of donor, or quantity of renal transplants received.
Compared to the conventional recovery group, the postoperative morphine PCA demand was considerably lower in the ER group.
Overall, the postoperative analgesia in the two groups was better since there were no significant variations in the amount of oral analgesia required.
Compared to patients who underwent standard recovery, living-donor kidney recipients’ hospital stays were significantly shorter (P .001), averaging 5 days and ranging from 3 to 9 days (median of 7 days; range, 5-30 days). When compared to patients who underwent conventional recovery, deceased-donor kidney recipients’ hospital stays were shorter (median of 5 days; range, 3–12 days) (P .001; Figure 3). (median of 8.5 days; range, 4-35 days).
Within 10 days following the transplant, 3 living donors (5.9%) and 4 deceased donors (6.4%) of kidney recipients were readmitted (1 patient developed ureteric obstruction and 6 patients had medical issues). Excellent patient satisfaction with early mobility, early resumption of oral intake, active involvement in treatment, and the ER program overall were shown in the patient satisfaction survey of the ER group.
Discussion:
The modalities used are :
The postoperative catabolic phase is known to be lessened and healing can be improved by carbohydrate loading. 12-14 This hasn’t been tried on ESRD patients, though. Due to its CHO content, we think it can help ESRD patients recover faster and may even reduce surgical hyperkaliemia.
Although postoperative pain following a kidney transplant may be considerable, the use of systemic analgesia may be constrained due to renal impairment and opioid-related respiratory problems.
Comparing intrathecal diamorphine to systemic morphine, it has been demonstrated that intrathecal diamorphine provides efficient postoperative pain control with a lower side effect profile. Regional anesthesia for kidney transplantation is still debatable. While a TAP block shown effectiveness in some tests, it was ineffective in others. Combining TAP block and ID in this review shown a considerable decrease in the need for PCA, with the patient relying primarily on oral analgesia.
Transesophageal Doppler was advised to be used in 2012 by the National Institute for Health and Care Excellence Guidelines to monitor fluid balance in patients who underwent significant operations. 28 Monitoring the central venous pressure to direct the fluid therapy can be imprecise and perhaps improper. The central venous pressure is not necessarily a good indicator of the patient’s fluid state or a responsive measure to fluid difficulties.
To evaluate postoperative fluid treatment, we used the clinical evaluation of the patient (fluid input and outflow, vital signs, primarily mean arterial pressure), together with daily weight measures. Only inotropic treatment in the intensive care unit or the administration of specific induction drugs were administered to ER patients using central lines (eg, thymoglobulin).
In these immunocompromised patients, earlier catheter removal lowers the risk of infection and promotes early mobilization.
Limitations of this study:
Although there was a historical control group, the hospital database included reliable information about how long each patient stayed. Only 23 patients’ information regarding their morphine needs in the control group was provided, although the trend is obvious from the data. Due to time restrictions and the inability to forecast the length of the procedure, CHO beverages were not supplied to all non-diabetic patients.
As this program depends on nursing personnel to administer and support the daily milestones, mobilization, and discharge, nursing care is of utmost importance.
2-Level of evidence 3
3-Through MDT work by early education, early catheter removal and early discharge.
Q1- In this study they want to implement an enhanced recovery program in an active way for post-operative recipients of renal transplant. The enhanced recovery program (ER) which is also called fast track or accelerated rehabilitation is not exactly defined. Its purpose is to have the best care with the given evidence on time and is used for post-operation in different fields.
Implementing ER in the case of the patient with CKD stage 5 having dialysis is hard due to immense comorbidities, cardiovascular in particular, which would be complications such as coronary artery disease (CAD), congestive heart failure (CHF), etc. In addition, the risk of slow healing of wounds, complications, and graft rejection is increased while using immunosuppression drugs, which would result in longer stay in hospital and more complications.
The ER program is designed to help with the fluid management, early mobilizing, controlling pain, restarting the bowel movement and oral intake, educating the patients and counselling.
Here are some situations that ER modality is implemented: transoesphageal doppler for fluid management, encourage mobilization as soon as the day of the operation, intrathecal diamorphine ID usage for controlling pain maybe which can be combined with TAP block to lessen the usage of postoperative systemic morphine that increases the risk of respiratory depression because of morphine’s cumulative effect and lessen the urge to have oral analgesics, administering ATG as induction would have central line usage when needed, mostly less than 5 days after operation would be the removal of urinary catheter, the role of loading meal of CHO and its effect on better healing of the wound and decreasing catabolic status after the operation, if not given more than 100 ml per day it would be possible to remove the wound drain in less than 48 hours after the operation.
As you can see, the above modality would result in more satisfaction from the patients, cost saving, and a better result in general.
Q2- A retrospective cohort study- level of evidence 3
Q3- I have implemented these modalities in my own experiences with patients and the patient discharge would usually be on the 6th day after the operation.
Objectives:
aim was to apply the principles of enhanced recovery in renal transplant recipients and
to assess the changes in the quality of patient care and patient satisfaction.
Introduction:
The concept of enhanced recovery (ER) within elective surgery has revolutionized our
surgical practice over the recent years since its introduction by Henrik Kehlet.
The ER program is about improving patient outcomes and speeding up a patient’s
recovery after surgery.
It benefits both patients and staff members.
The program focuses:
patients are active participants in their own recovery process
Patients always receive evidence-based care at the right time.
Improving patient care subsequently reduces the length of hospital stay.
Materials and Methods:
264 consecutive renal transplant patients,135 patients (60 living-donor transplants and
75 deceased-donor transplants) went through the ER program compared with 151
patients (85 living-donor transplants and 66 deceased-donor transplants) who had
traditional recovery.
. For living donor recipients, 40/60 ER patients (66%) received carbohydrate loading .
The patients received 4 CHO drinks on the day of admission and 2 CHO drinks on the
morning of surgery with no overnight fasting.
The last CHO drink was given 2 hours before transplant.
All patients were given light early breakfast at 6:00 AM (no solid food or any other oral
fluid after 6:00 AM, with only CHO allowed).
For deceased-donor recipients, 35/75 ER patients (46%) received 2 CHO drinks, while
waiting for cross-match results.
Intraoperative anesthetic care included goal directed fluid therapy using trans
esophageal Doppler to achieve adequate fluid balance and to avoid the use of central
lines.
Intrathecal diamorphine (ID; single dose of 200-600 μg) combined with ultrasonography-
guided transversus abdominis plane block (TAP block; 40 mL of 0.25% bupivacaine)
were administered to minimize patient controlled analgesia use of systemic morphine (1
mg/mL) and to improve the postoperative analgesia during the first 24 hours after
surgery.
Oral intake allowed few hours after the operation, allowing discontinuation of intravenous
fluid replacement within the first 24 hours after surgery.
Early mobilization was encouraged from the first postoperative day, allowing patients to
sit on a chair for 2 hours.
Mobility was gradually increased on the subsequent postoperative days.
Laxatives and oral analgesia were also commenced after discontinuation of the PCA
morphine on the first postoperative day.
Urinary catheters were removed 2 to 6 days after transplant (average of 4 days).
Wound drains, if used, were removed within the first 48 hours of surgery unless it was
productive (> 100 mL/24 h).
None of the patients in the traditional recovery group had CHO drinks; goal-directed fluid
therapy with trans esophageal .This group had 20 to 30 mL of bupivacaine 0.25% as
wound infiltration into the subcutaneous tissue.
Patient controlled analgesia morphine was also discontinued 24 hours after surgery.
The urinary catheter in the control group was removed on day 5 or sometimes later.
There was no agreed-on plan regarding removal of the surgical drain.
There was also no formal plan for early mobilization or planned discharge date.
Results:
The postoperative morphine PCA requirement was significantly reduced in the ER
group, compared with the traditional recovery.
There were no significant differences in the oral analgesia requirement between the 2
groups.
The length of hospital stay was significantly reduced for living donor kidney recipients
compared to traditional method.
Length of hospital stay was also reduced for deceased-donor kidney recipients .
patient satisfaction survey of the ER group demonstrated excellent patient satisfaction
with early mobility , early resumption of oral intake , active involvement in care and the
ER program as a whole .
Discussion:
This is the first published report addressing the applicability of the ER principle in renal
transplant.
ER program is a multidisciplinary, evidence based approach that benefits both patients
by improving their care and also the NHS by reducing the workload on the medical staff.
In addition, there is a reduction in the cost of treatment.
These were taken as surrogate markers of improved quality of care.
“multimodal package” is required to achieve these results. Fragmentation of this
treatment package would not be effective in providing quality care.
Preoperative patient counseling in association with good education is paramount for
success of the program.
Level of evidence 111.
It is multidiscipline approach to improve post operative care.
Application of this protocol need patient education ,staff commitment .
Briefly summarize this article highlighting the principal elements of enhanced recovery in renal transplant recipients.
· Enhanced recovery( ER) is multimodal recovery pathway to reduce post-operative pain and to accelerate recovery.
· The ER in kidney transplant recipients is very well elaborated in this article which compares patients treated conventionally with enhanced recovery protocols.
· Aim: To actively involve patients in this process to achieve early recovery, leading to early discharge and less hospital expenses.
· This program saved 2160£ per living donor and 3078£ for deceased donor transplant.
· key elements of ER pathway include:
– avoiding prolonged fasting, carbohydrate loading.
– Intra-operative:
· maintaining fluid balance through trans-esophageal ECHO rather than the CVP monitoring.
– Post operative:
· pain is alleviated with the use of intra-thecal diamorphine coupled with ultrasound guided transversus abdominis plain block.
· Encourage early mobilization and oral intake
· Use laxatives on the first post-operative day
· Early removal of drains after 48 hours if <100ml
· Early removal of urinary catheter (average was 4 days)
· Conclusion: patient group with enhanced recovery protocols had better outcomes , greater satisfaction and shorter hospital stay
What is the level of evidence provided by this article?
Case control study – level of evidence 3
How would you implement enhanced recovery in your workplace?
ER is a an ideal NHS approach which is cost-effective, time-saving for the medical staff and patients. It needs a full discussion between all members of the multidiscipline team to be implemented rather the conventional approach
Summary of A Better Journey for Patients, a Better Deal for the NHS: The Successful Implementation of an Enhanced Recovery Program After Renal Transplant Surgery Introduction
The program focuses on making surgery that patients are active participants in their own recovery process.
Also aims to ensure that patients always receive evidence-based care at the right time so improving patients’ care and reducing the length of hospital stay.
Within the review, we implement various modalities of pain control and fluid treatment.
Material and methods
Analyzed 269 renal transplant patients. For deceased- donor transplant recipients22/75 ER patients received kidneys and 26/62
Traditional recovery patients received kidneys from donors after cardiac death.
The length of hospital stay, morphine requirement, and the oral analgesic requirement were compared with historical controls from our database which did not have any of the ER elements mentioned above.
Results
There were no differences in patient characteristics between the ER group and the traditional recovery group.
The patient satisfaction survey of the ER group found excellent patient satisfaction with early mobility, early resumption of oral intake active involvement in care, and the ER program as a whole.
Discussion
ER program is evidence-based and benefits both parents by improving their care and reducing the workload on the medical staff. reduction in the cost of treatment reduction in the length of hospital stay and reduction in readmission rates with excellent patient satisfaction.
Limitation
1-the control group is historical.
2- morphine requirements of the control group were available for only 23 patients.
3- CHO drinks were not given to all nondiabetics patients.
4-the satisfaction survey included only the last 25 patients.
5-nursing care is important.
ER program does not only improve the quality of care of renal transplant patients but also provides other advantages by reallocating the nursing and medical staff to look after critically ill patients in the current national health service environment of shortage of health care workers.
case-control study level 3
by early oral intake postoperative, early mobilization, proper fluid management, proper analgesia and decrease postoperative analgesic
The concept of advanced recovery emerged for elective colonic surgeries, where a multimodal recovery is provided through more adequate control of postoperative pain, accelerating recovery. The program allowed for greater patient satisfaction, reduced length of hospital stay and readmissions and, consequently, lower costs in the modalities of live and deceased transplants.
Interventions performed in the advanced recovery program were:
– Preoperative counseling
– Carbohydrate consumption control – where a load of 200mL/carton was administered. There was improvement in postoperative hyperkalemia and wound healing.
-Analgesia with intrathecal diamorphine + transversus abdominis plane block guided by USG, using bupivacaine. There was less use of systemic morphine, with more effective pain control and greater early mobility.
– Use of Transesophageal Doppler to assess water balance;
– Early removal of urinary catheters and drains (provided the volume is less than 100ml per day)
This article has level 03 – is case control study.
Imagining the need to apply a package of measures, where the success of each item is necessary to reach the final result, all areas of the multidisciplinary team would require investment:
– Financial: purchase of devices and materials that are not normally used;
– Training: the multidisciplinary team should also undergo training in their different areas of intervention – anesthesiologists, nutritionists, nursing.
Aim of the study: assessing the impact of enhanced recovery/fast track or accelerated rehabilitation on the post-operative recovery of renal transplant recipients.
Study sample: total number of 286 patients, 135 patients renal transplant recipients having ER protocol vs 151 patients with traditional recovery.
Basic elements in the ER protocol include:
1- Active patient involvement in the recovery process.
2- Patient education from admission till discharge.
3- No overnight fasting, Carbohydrate loading on day of admission.
4- Transesophageal doppler to asses fluid status.
5- Intra-thecal diamorphine or transverse abdominal plane block for analgesia.
6- Try to stop IV fluids by the end of first day post-operatively by initiating free fluid intake early post-operatively.
7- Early removal of drains and urinary catheter.
Limitations of the study:
1- Control group was a historical group.
2- Morphine data was not available for all patients.
3- Carbohydrate drinks were not supplied to all non-diabetics.
4- Survey of satisfaction was not filled by every patient.
Level 3: no randomization, historical control group.
Requires MDT that includes surgeons, Nephrologists, ICU team, Dieticians.
It is already done in my center.
This is a controlled study – level III evidence
The concept of enhanced recovery was used as a rehabilitation program after colonic surgery, it was thought it was hard or even impossible to implement this system on the renal recipients but in fact it’s not
The main points and differences included :
-Avoidance of prolonged fasting
-Assessment of the fluid balance status by TEE
-Intrathecal diamorphine and ultrasonography-guided transverse abdominis plane blocks to decrease the postoperative PCA dose
-Early postoperative oral intake
-Early mobilization
Introduction:
Enhanced recovery is also known as “fast track” and “accelerated rehabilitation.” ESRD patients represent American Society of Anesthesiologists grade III with many comorbidities. Dialysis patients for instance have 8 times the mortality rate of their age-matched population with cardiovascular causes estimated for more than 50% of deaths, 84 %hypertensive and on more than 1 agent; 31% have congestive heart failure at the time of initiation of dialysis, with 25% developing congestive heart failure during the course of dialysis. Diabetes is the leading cause of chronic renal failure, thus 40%of ESRD are diabetic.
Postoperative care of renal transplant patients face many obstacles, the fact that Immunosuppression increases infection risk and delays wound healing in addition to challenges in perioperative fluid management. Also cases of delayed graft function may need dialysis and or renal biopsy to exclude rejection urging prolonged hospital stay or even readmission.
Modalities as pain control, fluid treatment, raising patient education, counseling, early restoration of oral intake, and early mobility were adopted to enhance the recovery postoperatively.
Materials and Methods
Total of 264 renal transplant patients were included, 135 patients (60 living-donor transplants and 75 deceased-donor transplants) went through the ER program compared with 151 patients (85 living-donor transplants and 66 deceased-donor transplants) who had traditional recovery.
Important factors involved mainly patient education. Regarding intraoperative anesthetic care Central lines were only used when inotropic support or thymoglobulin induction were required. Patient controlled analgesia (PCA) was adopted to improve the postoperative analgesia during the first 24 hours after surgery. Free oral intake was started when the patient condition allows following operation, to aid discontinuation of intravenous fluid replacement as much as possible. Early mobilization was encouraged from the first postoperative day. Patients were instructed to sit on a chair for 2 hours.
Laxatives and oral analgesia after discontinuation of the PCA morphine on the first postoperative day were administered. Urinary catheters were removed 2 to 6 days after transplant (average of 4 days).
Wound drains, if used, were removed within the first 48 hours of surgery unless it was productive (> 100 mL/24 h). All these encouraged patients’ dependent mobility.
Statistical analyses
Data were analyzed using SPSS. The Mann-Whitney U test was used for nonparametric continuous variables.
Results
No statistical differences were found between the ER group and the traditional recovery group regarding age, sex, type of donor, and number of renal grafts previously received.
The postoperative morphine PCA requirement was found to be less in the ER group compared to the traditional recovery group of P < .001. The patient satisfaction survey of the ER group showed excellent patient satisfaction with due to early mobility, early resumption of oral intake and active participation in the plan of care.
Discussion
ER program is a multidisciplinary, evidence based approach that benefits both patients by maximizing their care and also the NHS by minimizing the workload on the medical staff as well as the cost of prolonged hospital stay and requirement of readmissions. Excellent patient satisfaction was one of the surrogate markers of improved quality of care along with the previous markers.
Central venous pressure monitoring can be inaccurate to assess fluid status, so it is a must to be combined with clinical assessment of the patient mainly fluid input, output, vital signs and mean arterial pressure along with daily weight. Early removal of the catheter reduces the risk of infection in these known immunocompromised patients and encourages their early mobilization.
Limitations were obvious in the morphine requirements of the control group that were available for only 23 patients and the satisfaction survey which included only the last 25 patients.
Nursing care is the cornerstone of this structured pathway to implement and support the daily milestones, mobilization and discharge.
Level of evidence is category 3.
The implementation of Enhanced Recovery in my workplace is done via the facilitation of early resumption of oral intake, early mobilization, pain management and patient education.
The concept of enhanced recovery (ER) within elective surgery has revolutionized our surgical
practice over the recent years The technique was originally implemented as a rehabilitation program after colonic surgery with its principles centered on a multimodal recovery pathway to reduce post – operative pain and to accelerate recovery.
Patient education and discharge planning were commenced on admission. For enhanced recovery, prolonged pre – operative fasting was avoided by carbohydrate loading. Goal-directed fluid management was aided by transesophageal Doppler to avoid central line insertion.
Intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks were used to achieve adequate analgesia. Patients started oral intake a few hours postoperatively. The urinary catheter was removed 2 to 4 days after transplant.
This study included 286 consecutive renal transplant patients. Of these, 135
patients went through the enhanced recovery program and 151 patients had traditional recovery.
Results: The postoperative morphine PCA requirement was significantly reduced in the ER group (median of 4 mg; range, 0-56 mg) compared with the traditional recovery group (median of 53 mg; range, 10-140 mg) (P < .001). There were no significant differences in the oral analgesia requirement between the 2 groups, thus demonstrating overall better postoperative analgesia. The length of hospital stay was significantly reduced (P < .001) for living donor kidney recipients (median of 5 days; range, 3-9 days) versus patients who had traditional recovery (median of 7 days; range, 5-30 days). Length of hospital stay was also reduced for deceased-donor kidney recipients (median of 5 days; range, 3-12 days) (P < .001) compared with patients who had traditional recovery (median of 8.5
days; range, 4-35 days). Three living-donor (5.9%) and 4 deceased-donor (6.4%) kidney recipients were readmitted within 10 days of the transplant procedure.). The patient satisfaction survey of the ER group demonstrated excellent patient satisfaction with early mobility, early resumption of oral intake, active involvement in care, and the ER program as a whole.
Level 3
Involve all the medical, surgical, nursing, nutrition staff
Start discharge education and plan since admission
Early mobilization
Summary
The study was done to assess how enhanced recovery procedures can help increase the quality of care for the patient and improve patient satisfaction. A speedy patient recovery is the major goal guiding this effort. This is beneficial to everyone involved – the patient, the transplant team, and the healthcare system itself.
Major elements of enhanced recovery involved in this study include :
Level of evidence
Case control study – level of evidence 3
Implementing ER
Educating and counseling the patient from the time of admission onwards is something that we need to do more.
Reduced catheterization time is essential to implement in our centre where we tend to keep it for longer.
Early mobility will definitely be implemented.
This study was done in Sheffield kidney institute including 286 consecutive renal transplant recipients both living and deceased grafts to evaluate the enhanced recovery program which was applied on 135 recipients, the remainder, 151 recipients underwent the traditional recovery.
What is the enhanced recovery program?
This program was introduced by Henrik Kehalet as a rehabilitation program after colonic surgery to reduce the post-operative pain and enhance recovery.
It makes the patients to participate in their recovery and they are receiving evidence-based care at the correct time.
This program is also named fast track and accelerated rehabilitation.
Patients are given carbohydrate (CHO) loading (Nutrica preOp, 200 ml/ carton; Nutricia Medical, Wiltshire, UK).
The patients received 4 CHO drinks on the day of admission and 2 others on the morning of surgery 2 hours before transplant with no overnight fast.
All patients received light early breakfast at 6:00 AM.
All diabetic patient are excluded.
Fluids intra-operatively are given directed by trans-esophageal Doppler.
No central lines, they only used for inotropic support or thymoglobulin induction.
Intrathecal diamorphine combined with ultrasonography-guided transversus abdominis plane block.
Few hours after operation, oral intake was started with stopping of intravenous fluid replacement.
Early mobilization.
Laxatives and oral analgesia .
Removal of urinary catheters 2 to 6 days after transplant.
Wound drains removed within the first 48 hours of surgery unless the amount > 100 ml /24 h.
What is the outcome?
1- Reduction of patient hospital stay.
2- Reduction in the post-operative morphine PCA requirement.
3- Reduction of the workload on the medical staff.
4- Reduction in the cost treatment.
5- Excellent patient satisfaction.
This study is level 3
In our hospital we are doing traditional recovery. No carbohydrate given, overnight fast, Foley catheter removal on day 6 and discharge after one week..
This article discusses how the recovery post-operative can be improved which can reflect positively on the patient outcome. Implementation of enhanced recovery concept is difficult for ESRD as they have higher rate of comorbidities and mortality risk factors. Furthermore; post-operative care for kidney transplant patients is not straightforward due to many issues; Immunosuppression increases the risk of infection and delays wound healing. If the kidney does not function right away, dialysis is required. In addition, patients may also need a
kidney biopsy to exclude rejection of the trans planted kidney. This necessitates prolonged hospital stays or readmission. Perioperative fluid management is also challenging, especially in anuric patients, given the preexisting comorbidities.
The elements of ER are:
pain control
fluid treatment
patient education, counseling,
early resumption of oral intake,
and early mobility
A non-randomised controlled study, level III
It needs MDT and well-trained staff nurses but step by step it can be implemented. I will try to conduct the conclusion of this article to my colleagues and seniors as well
Briefly summarise this article highlighting the principal elements of enhanced recovery in renal transplant recipients
Since its introduction, the concept of enhanced recovery within elective surgery has revolutionised the surgical practice over recent years.
The technique was originally implemented as a rehabilitation program after colonic surgery with its principles centered on a multimodal recovery pathway to reduce post-operative pain and accelerate recovery.
Aim of the study: to apply the principles of enhanced recovery in renal transplant recipients and to assess the changes in the quality of patient care and patient satisfaction.
Methods:
The study included 286 renal transplant patients.
135 patients underwent the enhanced recovery program.
151 patients had traditional recovery.
Patient education and discharge planning were commenced on admission.
For enhanced recovery, prolonged preoperative fasting was avoided by carbohydrate loading. Goal-directed fluid management was aided by transesophageal Doppler to avoid central line insertion. Intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks were used to achieve adequate analgesia.
Patients started oral intake a few hours postoperatively.
The urinary catheter was removed 2 to 4 days after the transplant.
Results:
The postoperative patient-controlled analgesia requirement for morphine was significantly reduced in the enhanced recovery versus the traditional recovery group.
The length of stay was significantly reduced for living-donor and for deceased-donor transplant recipients with enhanced recovery versus recipients who had traditional recovery.
Implementing enhanced recovery saves £2160 per living-donor transplant and £3078 per deceased-donor transplant.
In the enhanced recovery group, readmission within 10 days after transplant was 5%.
Conclusion:
ER improved the quality of care for renal transplant patients and carried a financial benefits.
Limitations:
What is the level of evidence provided by this article?
Level 3 ( case-control study with historical controls ).
How would you implement enhanced recovery in your workplace?
In my institute, the surgeons do not remove drains or folly’s cath on day 4,
We don’t use morphine as a pain control modality, and we don’t use CHO loading.
Usually, central lines are used to control fluid balance in the intraoperative and postoperative periods.
The aim of this abstract was to assess the changes in the quality of patient care and patient satisfaction by applying the principles of enhanced recovery (ER) in renal transplant recovery. The aim of the ER is to improve patient outcome and to accelerate patient’s recovery after surgery.
The study included 286 renal transplant patients. 135 patients were given the ER program and 151 patients had traditional recovery. In the enhanced recovery group patients received carbohydrate in order to avoid prolonged pre-operative fasting. Central line was avoided by the administration of fluids with transesophageal Doppler. Patients received analgesia through intratecal diamorphine and ultrasonography guided tranversus abdominis plane block. Oral intake was commenced few hours after the procedure.
In the enhanced recovery group the postoperative requirement for morphine was remarkabl reduced compared to the traditional recovery group (9.5 vs 47 mg; P < .001). In the same group living donor transplant recipients and deceased donor transplant recipients had a shorter length of stay (respectively 5 vs 7 days; P < .001 and (median 5 vs 8.5 days; P< .001) compared to the traditional recovery group.
This is a case control study therefore level 3
We should organize a multidisciplinary approach with nephrologist, dietician, transplant surgeon and staff nurse.
.
In this article by Dr Halawa and collaegues have explored a fascinating idea of enhanced recovery in renal transplant patients which was previously considered appropriate only for other major surgical procedure.
There study included 286 consecutive renal transplant patients.
Of these, 135 patients went through the enhanced recovery program and
151 patients had traditional recovery.
Patient education and discharge planning were commenced on admission.
For enhanced recovery, prolonged pre- operative fasting was avoided by carbohydrate loading. Goal-directed fluid management was aided by transesophageal Doppler to avoid central line insertion. Intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks were used to achieve adequate analgesia. Patients started oral intake a few hours postoperatively. The urinary catheter was removed 2 to 4 days after transplant.
The postoperative patient-controlled analgesia requirement for morphine was significantly reduced in the enhanced recovery versus traditional recovery group (median of 9.5 vs 47 mg; P < .001).
The length of stay was significantly reduced for living-donor (median 5 vs 7 days; P < .001) and for deceased-donor transplant recipients (median 5 vs 8.5 days; P < .001) with enhanced recovery versus recipients who had traditional recovery.
Implementing enhanced recovery saves £2160 per living-donor transplant and £3078 per deceased-donor transplant.
Level of evidence 3
Enhanced recovery is a multidisciplinary approach. At our center transplant stay is for seven days and we have been able to achieve this in most of our cases.
patient is mobilized within 24 hrs
Drain is removed day 3 if all ok
Foleys is removed day seven
patient is usually switched to oral fluids on day 3.
Briefly summarize this article highlighting the principal elements of enhanced recovery in renal transplant recipients.
The aim of the study was to compare the efficacy of multidisciplinary approach in the postoperative period of kidney transplant recipient in relation to standard care.
The targets of the study were to :
1- Apply the principles of enhanced recovery in renal transplant recipients
2- Assess the changes in the quality of patient care and patient satisfaction.
286 consecutive renal transplant patients were included in the study. 135
patients received the enhanced recovery program and 151 patients received traditional recovery.
The enhanced recovery goals in this study included the following strategies:
– Early carbohydrate loading postoperatively
– Optimal fluid management directed by transesophageal Doppler to avoid central line insertion.
– Adequate analgesia achieved by intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks
– Early oral intake few hours postoperatively.
– Early removal of the urinary catheter – 2 to 4 days after transplant.
A- Early carbohydrate loading postoperatively.
Carbohydrate loading is known to reduce the postoperative catabolic phase and can enhance healing. It may counteract the postoperative hyperkaliemia due to its CHO content.
B- Optimal fluid management directed by transesophageal Doppler to avoid central line insertion.
– The National Institute for Health and Care Excellence Guidelines in 2012 recommended the use of transesophageal Doppler to monitor fluid balance in patients who had a major operation.
-Insertion of central line may can be associated with acute and chronic complication and the use of central line for CVP sequential measurements can be inaccurate and even inappropriate to guide the fluid therapy. Central line was used only as an access for inotropic treatment in hemodynamic unstable patients.
C- Adequate analgesia achieved by intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks.
The use of systemic morphine in the postoperative period can be associated with respiratory complication due to the delayed clearance of its active metabolite morphine-6-glucuronide in pts with delayed kidney function, whereas Intrathecal diamorphine has been shown to deliver effective postoperative pain control with better safety profile in comparison to systemic morphine.
D- Early oral intake few hours postoperatively.
E- Early removal of the urinary catheter – 2 to 4 days after transplant. In order to minimize the risk of UTI the catheter was removed as early as possible in these immunocompromised patients and also to encourage early ambulation.
Results:
1-More cost-effective
2- Significant reduction in the PCA morphine requirements, although the oral analgesic requirement were the same
3- Reduction in hospitalization stay
5- Reduction in readmission rates
2- What is the level of evidence provided by this article?
Level of evidence 2
3- How would you implement enhanced recovery in your workplace?
Enhanced recovery is a multidisciplinary approach which is cost-effective, time-saving for the medical staff and for the patient with lower risk of infection and readmission. This is ideal.
Enhanced recovery (ER) also called fast track or accelerated rehabilitation has been used to fasten recovery of patients post-operatively. The study assessed the effects of ER on outcomes KTR, included 135 consecutive renal transplant recipients who underwent ER protocol and were compared with 151 historical patients with traditional recovery.
ER group had per-operative counselling and education, then patients were given carbohydrate loading in form of carbohydrate drinks: 4 drinks on day of admission and 2 drinks with light breakfast on the morning of surgery without any overnight fasting. Intraoperatively, goal-directed fluid therapy using transesophageal doppler was given. Central-lines is best avoided unless for inotropes and rATG induction.
Intrathecal diamorphine with ultrasonography-guided transversus abdominis plane block was used to decrease PCA use of systemic morphine.
Early oral intake and early mobilization with early removal of urinary catheter and wound drains were also a part of the ER program post operatively.
The ER protocol shown to reduce requirement of PCA morphine, reduced LOS and reduced costs. It was also associated with excellent patient satisfaction due to early mobility, early oral intake and active involvement in care.
Limitations of the study included a historical control group, data regarding morphine use was not available for all the patients, carbohydrate drinks were not given to all non-diabetics and the satisfaction survey was also not filled by all the patients.
What is the level of evidence provided by this article?
Level 3
How would you implement enhanced recovery in your workplace?
The implementation of enhanced recovery requires multidisciplinary involvement of the transplant surgeon, anesthetists, nephrologists, critical care experts, dietitians, and the nursing staff.
This is something new knowledge to me, it is really fascinating and I am interested in implementing it. This new idea will be introduced to my unit and will try to implement it.
Briefly summarise this article highlighting the principal elements of enhanced recovery in renal transplant recipients.
This article summarize enhanced recovery protocol for Kidney Transplant Recipients. It has been introduced first in Colonic surgery and is a multimodal recovery pathway to reduce postoperative pain and facilitating recovery.
Protocols followed for enhanced recovery group are:
Preoperative:
1. Reducing periods of overnight fasting. Carbohydrate loading(CHO) drinks were given day prior admission (4 CHO drinks), light breakfast at 6am and 2 CHO drinks on day of surgery. No solid food or any other liquid except CHO drink after 6am on day of surgery. Last CHO drink given 2 hours before surgery. For deceased donor 2 CHO drinks received while waiting for crossmatch results.
Intra-operative:
2. Use of Trans-oesophageal doppler for goal directed fluid therapy
3. Avoidance of Central line except when required for ionotropic support or if induction immunosuppressive therapy (Thymoglobulin) is needed.
4. Intra-thecal Diamorphine (dose 200-600ug) with USG guided TAP block (40ml of 0.25% Bupivacaine). This will improve post-operative analgesia in first 24 hours and reduced patient-controlled analgesia (PCA) use of systemic morphine (1mg/ml).
Post-operative:
5. Free oral intake allowed few hours after surgery which allows stopping of IV fluids within 24 hours of surgery
6. Early mobilization and chair sitting for 2 hours commenced from first postoperative day and mobility gradually increased
7. Early discontinuation of PCA(Morphine) and use of Laxatives and oral analgesia on first POD
8. Urinary catheter removed between 2 to 6 days and drain if not more than 100ml/24hours, removed within first 48 hours
This study infers that Length of hospital stay, morphine requirement and oral analgesia requirement and hospital cost burden is low in enhanced recovery group (statistically significant).ER group has early mobility and oral intake with excellent patient satisfaction compared to traditional recovery group.
What is the level of evidence provided by this article?
The study is case control study so level of evidence in 3
How would you implement enhanced recovery in your workplace?
Implementation of ER protocol involves education of multi-disciplinary Kidney Transplant team which includes Surgeon, anesthetist, nephrologist, Transplant unit Nurses, Transplant coordinator/Patient educators, Physiotherapist for implementation and shared decision making with the patient.
Limited availability of trans-oesophageal doppler probes may be one factor that may not omit central lines in recipients intra-operatively at my place of work.
Introduction
Enhanced recovery(ER) technique was first used as a rehabilitation program after colonic surgery, it’s aim to reduce post – operative pain and to accelerate recovery.
The ER program is about improving patient outcomes and speeding up a patient’s recovery after surgery. It benefits both patients and staff members.
The program concentrate on making sure that patients are active participants in their own recovery process. It also aims to ensure that patients always receive evidence-based care when indicated
Improving patient care lead to reduction in hospital stay.
Renal transplant clinicians thought that the principle of ER would be not applicable in chronic renal failure patients undergoing renal transplant.
Postoperative care of renal transplant patients is not straightforward as:
· Immunosuppression increases the risk of infection and delays wound healing.
· If the kidney does not function immediately, dialysis is required.
· patients may need a kidney biopsy to exclude rejection of the trans – planted kidney.
· This necessitates prolonged hospital stays or readmission.
· Perioperative fluid management is also challenging, especially in anuric patients, given the preexisting comorbidities mentioned above
Materials and Methods
· 264 consecutive renal transplant patients were analyzed
· 135 patients of them (60 living-donor transplants and 75 deceased-donor transplants) went through the ER program compared with
· 151 patients (85 living-donor transplants and 66 deceased-donor transplants) who had traditional recovery
· For deceased-donor transplant recipients, 22/75 ER patients received kidneys and
· 26/62 traditional recovery patients received kidneys from donors after cardiac death
· Patient education and discharge planning were started on admission
Fluid management
· For living donor recipients, 40/60 ER patients (66%) received carbohydrate (CHO) loading (200 mL/carton).
· The patients received 4 CHO drinks on the day of admission and 2 CHO drinks on the morning of surgery with no overnight fasting. The last CHO drink was given 2 hours before transplant
· All patients were given light early breakfast at 6:00 AM (no solid food or any other oral fluid after 6:00 AM, with only CHO allowed)
· For deceased-donor recipients, 35/75 ER patients (46%) received 2 CHO drinks while waiting for cross-match results
Exclusion criteria: All diabetic patients were excluded (4/60 living-donor and 5/75 deceased-donor transplant recipients).
· To avoid central lines and achieve adequate balance of fluids, transesophageal doppler was used intraoperatively.
· Central lines were only used (10/60 living-donor recipients [16%] and 7/75 deceased-donor recipients [9%]) when inotropic support was required or when intravenous access was needed for thymoglobulin induction
Analgesia
Intrathecal diamorphine (ID; single dose of 200-600 μg) combined with ultrasonography-guided transversus abdominis plane block ( bupivacaine) were administered to reduce analgesia use of systemic morphine (1 mg/mL) and to improve the postoperative analgesia during the first 24 hours after surgery
Post Opperative:
Free oral intake was started a few hours after the operation, so intravenous fluid replacement was stopped within the first 24 hours after surgery.
Early mobilization was encouraged from the first postoperative day, allowing patients to sit on a chair for 2 hours. Mobility was gradually increased on the subsequent postoperative days.
Laxatives and oral analgesia were also given after stopping of the PCA morphine on the first postoperative day.
Urinary catheters were removed 2 to 6 days after transplant (average of 4 days).
Wound drains, if used, were removed within the first 48 hours of surgery unless it was productive (> 100 mL/24 h). This enabled early mobilization and continued patient education.
Statistical analyses: Data were analyzed using SPSS for Windows (SPSS: An IBM Company, version 19, IBM Corporation, Armonk, NY, USA).
Results
· There were no differences in patient characteristics (age, sex, type of donor, and number of renal grafts received) between the ER group and the traditional recovery group
· The postoperative morphine PCA requirement was significantly reduced in the ER group compared with the traditional recovery group
· There were no significant differences in the oral analgesia requirement between the 2 groups, thus demonstrating overall better postoperative analgesia.
· The length of hospital stay was significantly reduced for living donor kidney recipients versus patients who had traditional recovery.
· Length of hospital stay was also reduced for deceased-donor kidney recipients compared with patients who had traditional recovery.
· Three living-donor (5.9%) and 4 deceased-donor (6.4%) kidney recipients were readmitted within 10 days of the transplant procedure (1 patient developed ureteric obstruction and 6 patients had medical issues).
· The patient satisfaction survey of the ER group demonstrated excellent patient satisfaction with early mobility, early resumption of oral intake, active involvement in care, and the ER program as a whole.
· A 1-day hospital stay costs the NHS £513. Implementing the ER saves £2052 per living-related transplant (based on 4 days difference in the mean length of stay) and £2565 per deceased-donor transplant (based on 5 days difference in the mean length of stay).
Discussion
This ER program benefits both patients by improving their care and also the NHS by reducing the workload on the medical staff.
There is a reduction in the cost of treatment.
The authors found reduced PCA morphine requirements, reduced lengths of hospital stay, and reduced readmission rates in association with the excellent patient satisfaction
The authors believe that Carbohydrate loading is valuable in enhancing recovery in ESRD patients and may counteract the postoperative hyperkaliemia due to its CHO content.
The use of systemic morphine for postoperative analgesia after renal transplant must be monitored carefully due to the delayed clearance of its active metabolite in renal impairment, resulting in its
Intrathecal diamorphine has been shown to deliver effective postoperative pain control with a reduced adverse effect profile
The central venous pressure does not always give an accurate indication of the fluid status of the patient nor does it give a reliable response to fluid challenges
The authors relied on the clinical assessment of the patient (fluid input and output and vital signs, mainly mean arterial pressure) with daily weight measurements to gauge postoperative fluid therapy
Removing the catheter earlier reduces the risk of infection in these immunocompromised patients and encourages their early mobilization
Limitation of the study
· It involved a historical control group
· Morphine requirements of the control group were available for only 23 patients
· CHO drinks were not given to all nondiabetic patients due to time constraints
· The satisfaction survey included only the last 25 patients
What is the level of evidence provided by this article?
Level 3. A case controlled study
How would you implement enhanced recovery in your workplace?
Create multidisciplinary team with trained anesthetist on pain management, a dietitian, trained nurse, and a physiotherapist and try to apply this enhanced recovery with the same steps
Summery:
1.This study showed some promise not only early recovery of transplanted patients but also significant reduction of costs. Because, hospital stay and readmission reduced significantly.
2.Prolonged pre-operative fasting was avoided by carbohydrate loading pre-operatively.
3.Goal directed fluid management aided by transesophageal doppler in stead of central
line use.
4.Morphine use was less rather intrathecal diamorphin and usg guided transverse abdominis plane blocks were used.
5.Early removal of urinery catheter.
6.Early mobilization.
7.Early removal of wound drain.
Evidence: Level 3
I shall try to implement at least few of those in my workplace.
The article was a good one and it is about Hanirik Kehlet who was the first person that introduces an enhanced recovery (ER) program. The objective of the program is to improve the patient’s outcome and to reduce recovery time that is to ensure patients have a quicker recovery time post-surgery.
It is believed that since patients with CKD have multiple comorbidities like cardiovascular diseases, hypertension, and diabetes their recovery time would be delayed and as such, they are likely to get more complications. After these patients have been transplanted since they have high comorbidities, and the immunosuppressive medications they are more likely to develop infections, delayed wound healing, delayed response to treatment, and peri-operative treatment and fluids. In this regard, the study was conducted to ensure there is a better way for these patients to recover.
The study conducted was divided into groups but a total of 264 patients were divided into groups. One group included 135 patients of which 60 were living donors transplant and 75 were cadaveric donor transplant recipients who all followed the ER program or protocol.
1) This group received CHO loading drinks before surgery, it reduces postoperative catabolic state and enhances healing but not fully studied on ESRD.
2) They received intraoperative fluids which were guided by transoesophageal doppler.
3) Postoperative fluids therapy was guided by clinical assessments
4) Free oral fluid intake was given a few hours post procedure
5) They were mobilized early
6) Urinary catheters were removed within 2-6 days post-transplant
7) Drainage was removed in the first 48 hours if there are less than 100 cc /24 hours
The second group included 151 patients which 85 were live donors and 66 were cadaveric donors. This group has traditional recovery. The traditional recovery never had CHO drinks, transoesophageal Doppler, TAP blocks of ID. However, they received 20-30 ml of bupivacaine, and morphine was stopped 24 hours post-surgery.
What the study found was interesting and the following was noted:
1) There was a reduced PCA morphine requirement
2) Hospital stay was significantly reduced
3) Readmission also was reduced
4) It was noted that CHO in ESRD was needed for a faster recovery time.
5) Administration of morphine locally was effective for pain control when related to systemic control
6) Removal of catheter early reduced the risk of infection
7) Patients’ satisfaction was greater
8) Less work for the medical staff
The limitation of the study was that it included a historical control group, CHO was not given to all non-diabetic patients in the ER group and the satisfaction survey did not include all the patients.
The level of evidence provided in this group was level 4 evidence
Implementing this method in the workplace will be a great one but may be challenging due to the fact that the staff doesn’t have the experience and to move from a traditional form the entire group/team must be educated and trained. Once that is done and the fear is eliminated then I believe it can be implemented.
Enhanced recovery/ fast track or accelerated rehabilitation has been used to sped-up recovery of patients post-operatively. This study involved assessment of effects of enhanced recovery (ER) on outcomes of renal transplant recipients. A total of 286 patients were involved in the study. It included 135 consecutive renal transplant recipients who underwent enhanced recovery protocol and were compared with 151 historical patients with traditional recovery (TR).
In the ER group, after per-operative counselling and education, patients were given carbohydrate loading in form of carbohydrate drinks: 4 drinks on day of admission and 2 drinks with light breakfast on the morning of surgery without any overnight fasting. Diabetic patients were excluded.
Intraoperatively, goal-directed fluid therapy using transesophageal Doppler was given, avoiding central-lines except when needed for inotropes and ATG induction.
Intrathecal diamorphine with ultrasonography-guided transversus abdominis plane block was used to decrease patient-controlled analgesia (PCA) use of systemic morphine.
Post-transplant early oral intake and early mobilization with early removal of urinary catheter and wound drains were also a part of the ER program.
ER program was associated with reduced requirement of PCA morphine, reduced period of hospital stay and consequently reduced costs. It was also associated with excellent patient satisfaction due to early mobility, early oral intake and active involvement in care.
Limitations of the study included a historical control group, data regarding morphine use was not available for all the patients, carbohydrate drinks were not given to all non-diabetics and the satisfaction survey was also not filled by all the patients.
Level of evidence: Level 3: Controlled trial without randomization, involving historical controls
The implementation of enhanced recovery requires multidisciplinary involvement of the transplant surgeon, anaesthetists, nephrologists, critical care experts, dietitians, and the nursing staff. In my transplant unit, majority of patients are diabetics, who might not be an ideal candidate for this protocol. Nevertheless, non-diabetics can be enrolled in this program after discussions with all the stakeholders.
In our unit, which is a living donor transplant program, we do not insert wound drains and remove foley catheter by day 4. Central line insertion is required in view of ATG induction. Post-operative analgesia in form of morphine is rarely used. Hence most of the features of the ER protocol are being used in our unit (except the carbohydrate loading).
SUMMARY
Introduction:
The introduction of enhanced recovery (ER) method by Henric Kehlet has revolutionized the practice of elective surgery and it has helped greatly to reduce post operative pain and enhance speedy recovery of patients. Although it was originally designed as a rehabilitative program after colorectal surgery, but it has also been used in many other elective surgeries except in kidney transplantation.
ER empowers patients to be actively involved in their own care with support from medical staffs and together has been seen to reduce the length of hospital stay. However, there has been a resistance on the application of this concept to renal patient because of many accompanied comorbidities and attendant risk of infections post kidney transplant.
The concept of ER entails different modalities of pain and fluid control by patient education, early oral intake, and mobility.
Objectives:
1) to apply the concept of ER in renal transplantation recipient
2) to assess the changes in quality of patient care and satisfaction
Materials and Methods:
A total of 264 renal transplant patients divided into two arms of 135 for ER concept and 151 for traditional recovery method. Patient education and discharged planning were commenced on admission. The ER involves CHO loading in which patients received 4 CHO drinks on the day of admission and 2 CHO drinks on the morning of surgery with no overnight fasting and the last CHO drink was given 2 hours before transplant. Also, patients in both arms of the study were given light breakfast in the morning 6am. Free oral intake commenced few hours after the surgery and early mobilization encouraged from the first day of surgery.
Statistical analysis:
Data were analysed using SPSS for window (SPSS: An IBM company version 19, IBM corporation, Armonk, NY, USA)
Results:
Level of Evidence
How to implement
☆The Successful Implementation of an Enhanced Recovery Program After Renal Transplant Surgery.
_____________
In this service review: Various modalities of pain control and fluid treatment,
enhanced by patient education, counseling, early resumption of oral intake, and early mobility to enhance the recovery of living-donor transplant and
deceased-donor transplant pts were implemented.
Materials and Methods
▪︎This study included 286 consecutive renal transplant patients. Of these, 135 patients went through the enhanced recovery program and 151 patients had traditional recovery.
▪︎Patient education and discharge planning were commenced on admission. ▪︎For enhanced recovery (ER), prolonged pre – operative fasting was avoided by carbohydrate loading.
▪︎Goal-directed fluid management was aided by transesophageal Doppler to avoid central line insertion.
▪︎Intrathecal diamorphine and UD-guided transversus abdominis plane blocks were used to achieve adequate analgesia. ▪︎Patients started oral intake a few hours postoperatively.
▪︎The urinary catheter was
removed 2 to 4 days after transplant.
Results:
▪︎The postop patient-controlled analgesia requirement for morphine was significantly reduced in the ER versus traditional recovery (TR)group.
▪︎The length of stay was significantly reduced for living-donor and for deceased-donor transplant recipients with ER versus recipients who had TR.
▪︎In the ER group, readmission within 10 days after transplant was 5%.
Discussion:
▪︎ This is the 1st published report addressing the applicability of the ER program in renal transplant.
▪︎ER program benefits both patients by improving their care and also the NHS by reducing the workload on the medical staff.
▪︎There is a reduction in the cost of treatment, PCA morphine requirements, lengths of hospital stay, and readmission rates in association with the excellent pts satisfaction.
▪︎Preoperative patient counseling in association with good education is important for success of the program.
▪︎Carbohydrate loading can enhance healing.
▪︎The use of systemic morphine for postoperative analgesia after renal transplant must be monitored carefully
▪︎Intrathecal diamorphine has been shown to deliver effective postoperative pain control with a reduced adverse effect profile compared with systemic morphine.
▪︎Combining TAP block and ID together showed
significant reduction of the PCA requirement
▪︎In ER patients, the central line was used only as an access for inotropic treatment in the intensive care unit setting or for administration of certain induction agents (eg, thymoglobulin).
▪︎Early removal of the urinary catheter reduces the risk of infection and encourages their early mobilization.
☆Limitations of thisevaluation:
1. It involved a historical control group
2. Morphine requirements of the control group were available for only 23 patients, but the trend is clear from the available data.
3. CHO drinks were not given to all nondiabetic patients due to time constraints
4. The satisfaction survey included only the last 25 patients.
Notes: ER does not only improve the quality of care of renal transplant patients but also provides other patients with advantages
☆What is the level of evidence provided by this article? III
☆How would you implement enhanced recovery in your workplace?
To implement ER program we shall educate all the transplant team including nephrologists, surgeons anesthesiologist, urologist, dietian and nursing staff about the importance of this program and its applicability in kidney transplant recipients and tell them that the ER program benefits both types of renal transplant (living and deceased grafts) procedures, with excellent patient satisfaction and reduction of hospital length of stay and reduction in the cost of treatment.
level 1
I can also follow these strategies in my workplace
# Briefly summarise this article highlighting the principal elements of enhanced recovery in renal transplant recipients
*The aim of this study to utilise the principles of enhanced recovery(ER) in renal transplant recipients and to evaluate the changes in the quality of patient care and patient satisfaction, so the ER
program is about improving patient outcomes and speeding up a patient’s recovery after surgery.
*The introduction of (ER) within elective surgery by Henrik Kehlet, has revolutionized the surgical practice over the recent years
* The technique was originally implemented as a rehabilitation program post colonic surgery with its principles centered on a multimodal recovery pathway to decreas post -operative pain and to accelerate recovery.
# Materials and Methods:
In this study 286 consecutive renal transplant patients were involved, 135 patients went through the ER program and 151 patients had traditional recovery.
*Patient education and discharge planning were commenced on admission
*prolonged pre – operative fasting was avoided by carbohydrate loading.
*Goal-directed fluid management was aided by transesophageal Doppler to avoid central line insertion.
* Central lines were only used when inotropic support was required or for thymoglobulin induction
*Intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks were used to achieve adequate analgesia
*Patients started oral intake a few hours postoperatively
*Early mobilization was encouraged from the first postoperative day, allowing patients to sit on a chair for 2 hours then gradually increased on the subsequent postoperative days.
*Laxatives and oral analgesia were also com – menced after discontinuation of the PCA morphine on the first postoperative day.
* The urinary catheter was removed 2 to 4 days after transplant
# Results
*There were no differences in patient characteristics(age, sex, type of donor, and number of renal grafts received) between the ER group and the traditional recovery group
*The postoperative patient-controlled analgesia requirement for morphine was significantly reduced in the enhanced recovery versus traditional recovery group (median of 9.5 vs 47 mg; P < .001).
* The length of stay was significantly reduced for living-donor (median 5 vs 7 days; P < .001) and for deceased-donor transplant recipients (median 5 vs 8.5 days; P< .001) with enhanced recovery versus recipients who had traditional recovery.
* Implementing enhanced recovery saves £2160 per living-donor transplant and £3078 per deceased-donor transplant.
* In the enhanced recovery group, readmission within 10 days after transplant was 5%.
# What is the level of evidence provided by this article?
*Level 111
# How would you implement enhanced recovery in your workplace?
Because most the enhanced recovery (ER) elements are not available in my center, so I have to explain to transplant MDT that, the ER has great advantage for both types of renal transplant (living and deceased grafts) procedures, with excellent patient satisfaction and reduction of hospital length of stay, and discus with them how to find the appropriate ways to implement this program in our center, in addition to the necessity of educating the patients from the start.
* enhanced recovery (ER) was originally implemented as a rehabilitation program after colonic surgery to reduce post-operative pain and to accelerate recovery.
It was thought that it’s difficult to implement in chronic renal failure patients undergoing renal transplant due to presence of many comorbidities ( HTN ,cardiovascular disease,DM,etc).
Postoperative care of renal transplant patients is complicated due to many factors ,immunosuppression associated with higher incidence of infection and delay wound healing, the need for biopsy in some cases, Perioperative fluid management in dialysis patient is also problematic, and sometimes the need for dialysis with DGF.
this study aimed to evaluate implementation of ER in transplanted patients
*Materials and Methods
-264 renal transplant patients were included in the study.
135 patients (60 living-donor transplants and 75 deceased-donor transplants) went through the ER program
151 patients (85 living-donor transplants and 66 deceased-donor transplants) had traditional recovery.
-Patients in ER program received carbohydrate (CHO) loading to reduce postoperative catabolic phase and enhance healing.
The patients received 4 CHO drinks on the day of admission and 2 CHO drinks on the morning of surgery with no overnight fasting.
The last CHO drink was given 2 hours before transplant.
All patients were given light early breakfast at 6:00 AM
For deceased-donor recipients, 35/75 ER patients (46%) received 2 CHO drinks.
All diabetic patients were excluded.
-transesophageal Doppler to achieve adequate fluid balance and to avoid the use of central lines unless indicated for medications.
-Free oral intake few hours after the operation, to discontinue of IV infusion used for replacement in first 24 hours after surgery.
-Early mobilization was encouraged from the first postoperative day, allowing patients to sit on a chair for 2 hours.
-PCA to improve the postoperative analgesia during the first 24 hours after surgery.
Intrathecal diamorphine is effective postoperative pain control with a reduced adverse effect as respiratory distress compared with systemic morphine
-Urinary catheters were removed 2 to 6 days after transplant (average of 4 days) to reduces the risk of infection in immunocompromised patients.
-Wound drains, were removed within the first 48 hours
-None of the patients in the traditional recovery group had CHO drinks, goal-directed fluid therapy with transesophageal Doppler, TAP blocks, or ID.
Results- postoperative morphine PCA requirement was significantly reduced in the ER group.
-The length of hospital stay was significantly reduced for living-donor kidney recipients versus traditional recovery group. Length of hospital stay was also reduced also for deceased-donor kidney recipients.
-ER group demonstrated excellent patient satisfaction with early mobility and early resumption of oral intake , active involvement in care , and the program as a whole ,with lower cost for the ER program.
Authors emphasize that ER does not only improve the quality of care of renal transplant patients but also provides other patients with advantages by reallocating the nursing and medical staff to look after critically ill patients in the current National Health Service environment of shortage of health care workers.
Conclusion
This is the first published report addressing the applicability of the ER principle in renal transplant.
ER program is a multidisciplinary, evidence-based approach that benefits both patients and the NHS.
Preoperative patient counseling and education is essential for success of the program.
Level of evidence III
Applying ER program in my work would be of great importance to help patients of early mobilization, early hospital discharge, decreae readmission and decrease the cost.
Integrated and organised approach involves nephrologist ,anesthesiologist, and good nursing team , with good education to the patient will help to start applying the ER Program
Hanirik Kehlet was the first who introduce enhanced recovery(ER) program. ER program designed to improve patient outcome & fasten patient recovery after surgery. Previously there was a wrong believe about the benefit of ER in CKD patients due to presence of multiple co-morbidities as CVD, CHF, HT & DM. Post surgery there is an increase the risk of infection, poor wound healing an CVD due to use of immunosuppression & need to dialysis in DGF, in addition to the difficulty in peri operative fluid management.
Methods & materials:
264 KTR divided into 2 groups. Group 1 include 135 patients ( 60 living-donor transplant, 75 were deceased donor transplant recipients) who follow ER program. Group 2 include 151 KTR ( 85 were live-donor transplant & 66 were deceased-donor transplant) have traditional recovery.
Group1: 66% of living-donor transplant receive 4 CHO drinks on day of admission & 2 CHO drinks on morning of the surgery without overnight fasting, & all candidates receive light breakfast at 6:00AM. For deceased-donor recipients 46% receive 2 CHO drinks while waiting for cross-match results.
Intra-operative anesthetic care include:
Fluid oral intake introduce after few hours post transplant with early mobilization in first post operative day. laxatives & oral analgesia started after discontinuation of PCA morphine.
Group2:
Traditional recovery group, didn’t receive CHO drinks, trans-esophageal Doppler, TAP block of ID. But they receive 20-30 ml of bupivacaine 0.25% ( wound infiltration), morphine stopped 24 hours post operatives.
Length of hospital stay, morphine requirement was compared to historical control extrapolated from the database who didn’t receive any ER program elements.
Results & discussion:
This is the first published report about applicability of ER program in KTR. It was found :
Limitations of the study:
One of the important part of ER program is nursing care which support daily milestone, mobilization & discharge, in addition pre-operative education & post discharge follow-up.
Case control study, level 3.
In my country, traditional recovery used with clinical assessment of patients fluid inout & output, wight, & vital signs. Trans-esophageal Doppler technique not used.
ER is multidisciplinary program that improve the surgical practice over years, it is also known as fast track and accelerated rehabilitation, it depends on multimodal recovery pathway aiming to decrease post operative pain, accelerate recovery and improve patient outcome in addition to decreasing the workload on medical staff and decreasing the cost of treatment.
It ensures providing evidence based care at the appropriate time.
In ER program, the patients are active participants during recovery making the preoperative counselling and good education very important.
Nursing staff have major role in the program
ER program has several challenges when applied in patients with ESRD as
Materials and methods:
The study included 264 consecutive kidney transplant recipients, 135 had ER program and 151 had traditional recovery program.
In ER program:
The traditional recovery group didn’t receive CHO drinks, transesophageal doppler, ID or TAP block, urinary catheter removed on day 5 or later with no formal plan for removal of the drain, mobilization or discharge date.
Patients who went through ER programs had reduction n PCA morphia requirements, shortened hospital stay, reduced readmission and excellent patient satisfaction.
Level of evidence: 3 (non randomized controlled trial)
To implement ER program we need to educate all team members including nephrologists, anesthesiologist, urologist and nursing staff about the importance of this program and its applicability in kidney transplant recipients and informing them about its benefits compared to traditional recovery program
The ER program is about improving patient outcomes and speeding up a patient’s recovery after surgery.
The program focuses on making sure that patients are active participants in their own recovery process.
It also aims to ensure that patients always receive evidence-based care at the right time.
“fast track” and “accelerated rehabilitation.
Materials and Methods
264 patients
(85LD- 66DD)
( 4 CHO drinks on the day of admission and 2 CHO drinks on the morning of surgery with no overnight fasting. )
All patients were given light early breakfast at 6:00 AM
Central lines were only used when inotropic support was required or when intravenous access was needed for thymoglobulin induction, an immunosuppressive drug that requires central venous access for administration.
Mobility was gradually increased on the subsequent postoperative days.
The end point of comparison between the two group ER VS NON ER (traditional)
1 Patient-controlled Analgesia Morphine Requirement
2 Length of Hospital Stay After Renal Transplant
3 This enabled early mobilization and continued patient education
4 The cost effect of ER program
Statistical analyses Data
using SPSS for Windows
• . t test for comparisons of parametric continuous variables.
• U test was used for nonparametric continuous variables.
• Comparisons of nominal and categorical data were performed by means of the chi-square test
Results
• The postoperative morphine PCA requirement was significantly reduced in the ER group
• There were no significant differences in the oral analgesia requirement between the 2 groups, thus demonstrating overall better postoperative analgesia.
• The length of hospital stay was significantly reduced for living and deceased donor kidney recipients versus patients who had traditional recovery
• Implementing the ER saves £2052 per living-related transplant (based on 4 days difference in the mean length of stay) and £2565 per deceased-donor transplant (based on 5 days difference in the mean length of stay).
Conclusion;
practical “multimodal package” to achieve these results. Fragmentation of this treatment package would not be effective in providing quality care. Preoperative patient counseling in association with good education is paramount for success of the program.
Non randomized controlled trial level III
If we decide to implement enhanced recovery in our medical center we should start training multidisciplinary teamwork (nurses- anesthesiologist- urologists- nephrologist- nutritionist- interventional pain specialist…..)
· Multidisciplinary approach in the postoperative care of kidney transplant recipients will enhance the patient outcomes.
· Early carbohydrate loading postoperatively to prevent hypercatbolic state and improve wound healing.
· Optimal fluid management guided by transesophageal Doppler intraoperatively rather than CVP monitoring, as recommended by National Institute for Health and Care Excellence Guidelines in 2012 for any major surgery, to avoid CVC insertion with its complications.
· Central line was used only as an access for inotropic treatment in unstable patients.
· Early introduction of oral fluids intake few hours postoperatively to avoid bacterial translocation and improve metabolic state.
· Early removal of the urinary catheter – 2 to 4 days after transplant, to minimize risk of UTI in such patient with large doses of immunosupression.
· Adequate analgesia to control post operative pain, achieved by intrathecal diamorphine to avoid systemic morphine which can cause respiratory center depression due to limited clearance in case of delayed graft function.
· Target of this approach:
o Decrease cost, hospital stay.
o Better graft and patient outcomes.
o Decrease load on working staff
· level of evidence 4.
· 3– How would you implement enhanced recovery in your workplace?
Program After Renal Transplant Surgery
Briefly summarise this article highlighting the principal elements of enhanced recovery in renal transplant recipients.
Introduction
The concept of enhanced recovery (ER) in elective surgery (originally for colorectal surgery) was 1stintroduced by Henrik Kehlet.
ER is a multimodal recovery pathway to:
– Reduce post-operative pain
– Accelerate recovery, &
– Improve patient outcomes after surgery.
– It also benefits staff members.
In ER, the patients are active participants in their own recovery process; they always receive a timely evidence-based care with subsequent reduction in the length of hospital stay.
Terms like “fast track” & “accelerated rehabilitation” also describe the same principles as ER.
Postoperative care of renal transplant patients is complex & prolonged hospital stays or readmission might be needed b/c:
– The use of IS medications increases the risk of infection & delay wound healing.
– Dialysis is required if the graft does not function the right away.
– Patients may need a kidney biopsy to exclude rejection of the kidney.
– Fluid management is challenging, especially in anuric patients.
Materials and Methods
Population:
A 264 consecutive renal transplant patients. Of these, 135 patients (60 LD transplants & 75 DD transplants) went through the ER program versus 151 patients (85 LD transplants & 66 DD transplants) who had traditional recovery.
Interventions:
– Patient education & discharge planning started on admission.
– Patients given 4 CHO drinks on the day of admission & 2 CHO drinks on the morning of surgery with no overnight fasting.
– All patients were given light early breakfast at 6:00 AM.
– For DD recipients, 35/75 ER patients (46%) received 2 CHO drinks while waiting for XM results.
– All diabetic patients were excluded.
Intra-& peri-operative care included:
– Goal directed fluid therapy using trans-esophageal Doppler to achieve adequate fluid balance & to avoid the use of central lines.
– Central lines were only used when inotropic support was required or for ATG administration.
– Intrathecal diamorphine (ID) combined with U/S guided transverses abdominis plane block (TAP) were given to minimize patient controlled analgesia (PCA) use of systemic morphine & to improve the postoperative analgesia during the first 24 hours after surgery.
– Free oral intake was started a few hours postoperation, allowing discontinuation of IV fluid replacement within the first 24 hours.
– Early mobilization encouraged from 1st postoperative day, allowing patients to sit on a chair for 2 hours. Mobility was gradually increased on the subsequent days.
– Laxatives & oral analgesia were started after discontinuation of the PCA morphine on the first postoperative day.
– Urinary catheters were removed 2 to 6 days after transplant.
– Wound drains, if used, were removed within the first 48 hours of surgery unless it was productive (>100 mL/24 h). This enabled early mobilization &continued patient education.
– None of the patients in the traditional recovery group had CHO drinks, goal directed fluid therapy with trans-esophageal Doppler, TAP blocks, or ID.
Results
No differences in patient characteristics between the ER group & the control group.
The postoperative morphine PCA requirement was significantly reduced in the ER group.
No significant differences in the oral analgesia requirement between the 2 groups,indicating overall better postoperative analgesia).
The length of hospital stay was significantly reduced for LD kidney recipients versus patients who had traditional recovery.
Length of hospital stay was also reduced for
DD kidney recipients compared with patients who had traditional recovery.
The patient satisfaction survey of the ER group showed excellent patient satisfaction (early mobility, early resumption of oral intake, active involvement in care).
Conclusions
Reduced PCA morphine requirements, reduced lengths of hospital stay, & reduced readmission rates in association with the excellent patient satisfaction.
Intrathecal diamorphine delivers effective pain control with a reduced adverse effect profile compared with systemic morphine.
Combining TAP block & ID together in showed significant reduction of the PCA requirement.
NIH & Care Excellence Guidelines in 2012 recommended the use of trans-esophageal Doppler to monitor fluid balance in patients who had a major operation.
Removing the catheter earlier reduces the risk of infection & encourages early mobilization.
=========================
What is the level of evidence provided by this article?
Level III evidence
=========================
How would you implement enhanced recovery in your workplace?
Currently in our transplant center we are more or less following the traditional recovery in most of our patients.
Many of the components of the ER mentioned in this article are, unfortunately, not available in our centers. TAP block & ID are not practiced by our anesthetists. We don’t have Trans-esophageal Doppler services; we use central lines instead.
However, we always educate our patients pre-,peri-& post-operatively & encourage them to be actively involved in their own recovery. We remove catheters after 5 to 7 days; the drains are removed when volume is less thn 100ml for at least 2 consequtive days.
Aim of this study is to show the effect of enhanced recovery (ER) in renal transplant recipients of both types (living /deceased grafts) on the Quilty of patient care and satisfaction also how it will improving the outcome and speeding up patient recovery .
it was challenging to use ER in such patients with many comorbidities beside ESRD and possible multiple complications postoperatively .
ER using the following principles to reach its aim
Results were
—————————————————————————————-
Level III
Evidence obtained from well-designed controlled trials without randomization (i.e. quasi-experimental).
——————————————————————————————
it need well designed training program for all transplant medical team including nurses
as mentioned on the study that nursing care is hugely important, as this program relies on nursing staff to implement and support the daily milestones, mobilization, and discharge.
Summary
A Better Journey for Patients, a Better Deal for the NHS: The Successful Implementation of an Enhanced Recovery Program After Renal Transplant Surgery
An Enhanced Recovery program is about improving patient outcomes and speeding up a patient’s recovery after surgery and hence shortening hospital saty. Both patients and staff tend to benefit from ER.
Principal elements of enhanced recovery in renal transplant recipients:
· Goal- directed fluid therapy using transesophageal Doppler to achieve adequate fluid balance and to avoid the use of central lines.
· Central lines were only used when inotropic support was required or when intravenous access was needed for thymoglobulin induction.
· Intrathecal diamorphine (ID; single dose of 200-600 μg) combined with ultrasonography-guided transversus abdominis plane block.
· Free oral intake a few hours after the operation to allow discontinuation of IV fluids replacement.
· Early mobilization in the first postoperative day.
· Laxatives and oral analgesia to be commenced after discontinuation of the PCA morphine on the first postoperative day.
· Removal of urinary catheters, 2 to 6 days after transplant operation.
· Removal of wound drains, if used, within the first 48 hours of surgery unless it was productive (> 100 mL/24 h).
level of evidence: III
To implement ER program, the followings are needed:
· MDT.
· Patient education.
· Well trained staff.
· Equipment and facilities.
. Briefly summarise this article highlighting the principal elements of enhanced recovery in renal transplant recipients.
-The concept of enhanced recovery (ER) was originally implemented as a rehabilitation program after colonic surgery with its principles centered on a
multimodal recovery pathway to reduce post – operative pain and to accelerate recovery.
-Postoperative care of renal transplant patients is not straightforward. Immunosuppression increases the risk of infection and delays wound healing. If the kidney does not function right away, dialysis is required. In addition, patients may also need a kidney biopsy to exclude rejection of the transplanted kidney. This necessitates prolonged hospital stays or readmission.
-264 renal transplant patients involved in the study.Of these, 135 patients (60 living-donor transplants and 75 deceased-donor transplants) went through the ER program compared with 151 patients (85 living-donor transplants and 66 deceased-donortransplants) who had traditional recovery.
-Patient education and discharge planning were commenced on admission. For living donor recipients, 66% received carbohydrate (CHO) loading . The patients received 4 CHO drinks on the day of admission and 2 CHO drinks on the morning of surgery with no overnight fasting. The last CHO drink was given 2 hours before transplant. All patients were given light early breakfast at 6:00 AM
– For deceased-donor recipients, 46% received 2 CHO drinks while waiting for cross-match results.
– All diabetic patients were excluded .
-Intraoperative anesthetic care included goal directed fluid therapy using transesophageal Doppler to achieve adequate fluid balance and to avoid the use of central lines.
– Central lines were only used when inotropic support was required or when intravenous access was needed for thymoglobulin induction, an immunosuppressive drug that requires central venous access for administration.
–Intrathecal diamorphine ( ID ,single dose of 200-600 μg) combined with ultrasonography-guided transversus abdominis plane block (TAP,40 mL of 0.25% bupivacaine) were administered to minimize patient controlled analgesia use of systemic morphine (1 mg/mL) and to improve the postoperative analgesia during the first 24 hours after surgery.
-Free oral intake was commenced a few hours after the operation, allowing discontinuation of intravenous fluid replacement within the first 24 hours after
surgery.
-Early mobilization was encouraged from the first postoperative day, allowing patients to sit on a chair for 2 hours. Mobility was gradually increased
on the subsequent postoperative days.
-Laxatives and oral analgesia were also commenced after discontinuation of the PCA morphine on the first postoperative day. Urinary catheters were
removed 2 to 6 days after transplant (average of 4 days).
-Wound drains, if used, were removed within the first 48 hours of surgery unless it was productive(> 100 mL/24 h). This enabled early mobilization and continued patient education.
– None of the patients in the traditional recovery group had CHO drinks, goal-directed fluid therapy with transesophageal Doppler, TAP blocks, or ID. This
group had 20 to 30 mL of bupivacaine 0.25% as wound infiltration into the subcutaneous tissue.
– Carbohydrate loading is known to reduce the postoperative catabolic phase
and can enhance healing.
-Postoperative pain after renal transplant may be severe, but administration of systemic analgesia may be limited due to impaired renal function and respiratory complications from opioids.
– Intrathecal diamorphine has been shown to deliver effective postoperative pain control with a reduced adverse effect profile compared with systemic morphine.
– Removing the catheter earlier reduces the risk of infection in these immunocompromised patients and encourages their early mobilization.
-It was deferred to ensure the maturity of the ER program but still gives a meaningful conclusion and also guides the future development of the
program.
-Nursing care is hugely important, as this program relies on nursing staff to implement and support the daily milestones, mobilization, and discharge. This may be best implemented in the form of structured care pathways.
-ER does not only improve the quality of care of renal transplant patients but also provides other patients with advantages by reallocating the nursing and medical staff to look after critically ill patients in the current environment of shortage of health care workers.
What is the level of evidence provided by this article?
Level II
How would you implement enhanced recovery in your workplace?
-Patient education and discharge planning were commenced on admission.
-Carbohydrate (CHO) loading (All diabetic patients will be exclude ).
– Directed fluid therapy using transesophageal Doppler to achieve adequate fluid balance.
– Central line only use when inotropic support is required or thymoglobulin induction.
–Intrathecal diamorphine ( ID ,single dose of 200-600 μg) combined with ultrasonography-guided transversus abdominis plane block (TAP,40 mL of 0.25% bupivacaine) .
-Free oral intake commencesa few hours after the operation .
-Early mobilization was encouraged from the first postoperative day .
-Laxatives and oral analgesia commenced after discontinuation of the morphine on the first postoperative day.
-Urinary catheter removes 2 to 6 days after transplant (average of 4 days).
-Wound drains, if used, will be removed within the first 48 hours of surgery unless it was productive(> 100 mL/24 h).
1- Briefly summarize this article highlighting the principal elements of enhanced recovery in renal transplant recipients.
The aim of the study was to compare the efficacy of multidisciplinary approach in the postoperative period of kidney transplant recipient in relation to standard care.
The targets of the study were to :
1- Apply the principles of enhanced recovery in renal transplant recipients
2- Assess the changes in the quality of patient care and patient satisfaction.
286 consecutive renal transplant patients were included in the study. 135
patients received the enhanced recovery program and 151 patients received traditional recovery.
The enhanced recovery goals in this study included the following strategies:
– Early carbohydrate loading postoperatively
– Optimal fluid management directed by transesophageal Doppler to avoid central line insertion.
– Adequate analgesia achieved by intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks
– Early oral intake few hours postoperatively.
– Early removal of the urinary catheter – 2 to 4 days after transplant.
A- Early carbohydrate loading postoperatively.
Carbohydrate loading is known to reduce the postoperative catabolic phase and can enhance healing. It may counteract the postoperative hyperkaliemia due to its CHO content.
B- Optimal fluid management directed by transesophageal Doppler to avoid central line insertion.
– The National Institute for Health and Care Excellence Guidelines in 2012 recommended the use of transesophageal Doppler to monitor fluid balance in patients who had a major operation.
-Insertion of central line may can be associated with acute and chronic complication and the use of central line for CVP sequential measurements can be inaccurate and even inappropriate to guide the fluid therapy. Central line was used only as an access for inotropic treatment in hemodynamic unstable patients.
C- Adequate analgesia achieved by intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks.
The use of systemic morphine in the postoperative period can be associated with respiratory complication due to the delayed clearance of its active metabolite morphine-6-glucuronide in pts with delayed kidney function, whereas Intrathecal diamorphine has been shown to deliver effective postoperative pain control with better safety profile in comparison to systemic morphine.
D- Early oral intake few hours postoperatively.
E- Early removal of the urinary catheter – 2 to 4 days after transplant. In order to minimize the risk of UTI the catheter was removed as early as possible in these immunocompromised patients and also to encourage early ambulation.
Results:
1-More cost-effective
2- Significant reduction in the PCA morphine requirements, although the oral analgesic requirement were the same
3- Reduction in hospitalization stay
5- Reduction in readmission rates
6- Excellent patient satisfaction
7- Less workload on the medical staff
2- What is the level of evidence provided by this article?
Level of evidence 2
3- How would you implement enhanced recovery in your workplace?
Enhanced recovery is a multidisciplinary approach which is cost-effective, time-saving for the medical staff and for the patient with lower risk of infection and readmission. This is ideal. However, discrepancy in pre-operative and post-operative protocols between different hospitals and societies limits its use. I believe that every hospital should implement its own protocol based on availability of the multidisciplinary team, infection control team, nutritionists, clinical pharmacists.
Briefly summarise this article highlighting the principal elements of enhanced recovery in renal transplant recipients.
This article is about application of enhanced recovery protocols in renal transplant recipients. It compares patients treated conventionally and with enhanced recovery protocols.
Its purpose is to involve actively the patient in this process so that an early recovery can be achieved . This will lead too early discharge and less hospital expenses.
With enhanced recovery programme there was less need for morphine. There was short hospital stay in this group.
This programme saved 2160£ per living donor and 3078£ for deceased donor transplant.
This study concluded that patient group with enhanced recovery protocols had better comes with great patient satisfaction and short hospital stay.
What is the level of evidence provided by this article?
Cohart study Level 1V
How would you implement enhanced recovery in your workplace?
I will plan and try to materialize patient education and counselling
Early mobilisation on first post operative day
Adequate analgesia
Early start of oral intake
Use of laxatives
Adequate pain control
Clinical assessment and goal directed therapy for fluids
Early removal of catheters and drains
Dedicated discharge planning
After reading this article I plan to start enhanced recovery protocols in my department
1-Briefly summarise this article highlighting the principal elements of enhanced recovery in renal transplant recipients.
The enhanced recovery (ER) principles centered on a multimodal recovery pathway to reduce post-operative pain and to accelerate recovery.
Postoperative care of renal transplant patients is not straightforward because ;
1-Immunosuppression increases the risk of infection and delays wound healing.
2-Patients may need dialysis or kidney biopsy .
3-Perioperative fluid management is also challenging, especially in anuric
patients.
Enhanced recovery (ER) modalities,used in this study included ;
1-prolonged pre-operative fasting was avoided by carbohydrate loading.
Carbohydrate loading is known to reduce the postoperative catabolic phase
and can enhance healing. It may counteract the postoperative hyperkaliemia due to its CHO content.
2- Goal-directed fluid management was aided by transesophageal Doppler to avoid central line insertion.
-The National Institute for Health and Care Excellence Guidelines in 2012 recommended the use of transesophageal Doppler to monitor fluid balance in patients who had a major operation.
-Central venous pressure monitoring can be inaccurate and even inappropriate to guide the fluid therapy.
-The study relied on the clinical assessment of the patient (fluid input and output and vital signs, mainly mean arterial pressure) with daily weight measurements to gauge postoperative fluid therapy.
– In ER patients, the central line was used only as an access for inotropic treatment in the intensive care unit setting or for administration of certain induction
agents (eg, thymoglobulin).
3- Intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks were used to achieve adequate analgesia.
-The use of systemic morphine for postoperative analgesia after renal transplant must be monitored carefully due to the delayed clearance of its active metabolite morphine-6-glucuronide in renal impairment, resulting in its accumulation and subsequent respiratory depression.
– Intrathecal diamorphine has been shown to deliver effective postoperative pain control with a reduced adverse effect profile compared with systemic morphine.
4-Patients started oral intake a few hours postoperatively.
5-The urinary catheter was removed 2 to 4 days after transplant.
Removing the catheter earlier reduces the risk of infection in these immunocompromised patients and encourages their early mobilization.
The aim of the study was to ;
1-Apply the principles of enhanced recovery in renal transplant recipients
2-Assess the changes in the quality of patient care and patient satisfaction.
Population ;
The study included 286 consecutive renal transplant patients. Of these, 135
patients went through the enhanced recovery program and 151 patients had traditional recovery.
The study result ;
The ER program is a multidisciplinary, evidence-based approach that benefits both patients by improving their care and also the NHS by;
1- Reducing the workload on the medical staff.
2- Reducing the cost of treatment.
3- Reducing the PCA morphine requirements,
4- Reducing lengths of hospital stay.
5- Reducing readmission rates in association with the excellent patient satisfaction.
Limitation of the study ;
1-It involved a historical control group; however, the length of stay was accurately recorded in the hospital database.
2-Morphine requirements of the control group were available for only 23 patients, but the trend is clear from the available data.
3- CHO drinks were not given to all non diabetic patients due to time constraints, mainly because there was an inability to predict the operation time.
4- The satisfaction survey included only the last 25 patients.
2- What is the level of evidence provided by this article?
Cohort study ( Level IV)
3-How would you implement enhanced recovery in your workplace?
1-Patient education and discharge planning should be commenced on admission.
2-Goal-directed fluid therapy , should be relied on the clinical assessment of the patient (fluid input and output and vital signs, mainly mean arterial pressure) with daily weight measurements to gauge postoperative fluid therapy.
3-Free oral intake should be commenced a few hours after the operation, allowing discontinuation of intravenous fluid replacement within the first 24 hours after surgery.
4-Early mobilization should be encouraged from the first postoperative day.
5-Laxatives and oral analgesia must be commenced early .
5-Urinary catheter should be removed 2 to 6 days after transplant (average of 4
days).
7-Wound drains, if used, should be removed within the first 48 hours of surgery unless it was productive (> 100 mL/24 h).
Application of enhanced recovery in kidney transplant recipients is very well elaborated in this article and comparison between role of enhanced recovery in transplant recipients versus patient treated conventionally done. It’s main aim is to involve the patients actively to improve their outcome Hospital stay and total cost
and also analgesia requirement (morphine)
was reduced in ER group .
The key elements include:
Carbohydrate loading and avoiding prolonged fasting.
Transesophageal echo should be used to maintain fluid balance intraoperatively, rather than the cvp monitoring.
Post operatively,pain can be relieved with Intra-thecal diamorphine along with ultrasound guided transversus abdominis plain block.Encourage oral water intake and early mobilisation ..laxatives also to be given on first post op day and drains to be removed after 48 hours if <100ml and foly Catheter after 4 dayz(average).
What is the level of evidence provided by this article?
*** level of evidence 4- well-designed -cohort study
How would you implement enhanced recovery in your workplace?
Multidisciplinary team (including nephrologists,surgeons,dietician,cardiologist, nurses,critical care specialists )should be taken on board .Standard policies ànd protocols should be made and patients should be counselled about discharge and medicines.Hospital administration should be involved.In order to ensure it is being followed ,audit should be carried out.
-Introduction
Enhanced recovery (ER)was first applied as a rehabilitation program post colonic surgery to enhance recovery and reduce pain ensuring participation of the patient in his recovery process.
ER was then introduced to other surgical procedures enhancing patient’s care and reducing his hospital length of stay.
RTR candidates are categorised by American Society Anesthesiologists as grade III due to the presence of many comorbidities since ESRD patients on dialysis have high mortalilty rate out of cardiovascular events.
Coronary artery disease severity increase with decreased GFR.
Post operative care for RTR is challenging particularly if kidney function was not attained immediately post surgery as the patient can need dialysis and biopsy can be done to exclude rejection resulting in prolongation of hospital stay.
Immunosuppressives increases infection risk and delays wound healing also fluid management is crucial specially for anuric cases.
Methods
This study investigated 60 living-donor transplants and 75 deceased-donor transplants undergoing ER program compared to 85 living-donor transplants and 66 deceased-donor transplants whom had traditional recovery.
For living donor recipients, 66% were given carbohydrate (CHO) loading. All patients were given light early breakfast at 6:00 AM.
For deceased-donor recipients,46% received 2 CHO drinks till
cross-match results are released and diabetic patients were excluded.
Intraoperative anesthetic care in the forum of goal directed fluid therapy by transesophageal doppler ,to avoid central line usage except for immunosuppressive intake as thymoglobulin.
Intrathecal diamorphine with ultrasonography-guided transversus abdominis plane block was given to improve the postoperative
analgesia within the first 24 hours post surgery.
Oral intake was started few hours post surgery with early mobilisation gradually increased to shorten recovery period.
Urinary catheters were removed 2 to 6 days after transplant as well as wound drains removed within 48 h after surgery if not productive.
The group of patients exposed to traditional management had 20 to 30 mL of bupivacaine 0.25% as wound infiltration into the subcutaneous tissue and morphine was discontinued
24 hours post surgery and urinary catheter was removed on day 5 or later.
Results
The postoperative morphine PCA given was significantly lower in the ER group in comparison to traditional group.
The length of hospital stay was significantly less for living donor kidney recipients and deceased donor recipient receiving ER compared to patients who had traditional recovery .
The patient satisfaction survey of the ER group revealed statisfaction with early rehabilitation.
the ER saved £2052 per living-related transplant and £2565 per deceased-donor transplant.
Discussion
ER program is a multidisciplinary beneficial to the patient and to the NHS as well.
ER reduced PCA morphine requirements, shortened hospital stay, and lowered readmission rates with excellent patient satisfaction, decreased the work and financial burden on NHS and enhanced the care provided to the patients.
Preoperative patient education is essential for successful outcomes.
The ER program included multiple modalities applied together in a structured, well-designed care pathway, so that favourable outcomes are achieved. Carbohydrate loading can improve healing and can counteract postoperative hyperkalemia in ESRD .
Intrathecal diamorphine can deliver effective
postoperative pain relief ,decreasing the hazardous adverse
effects of systemic morphine accumulating with renal impairment.
TAP block and ID combined usage reduced PCA requirement.
In 2012 the National Institute for Health and Care Excellence Guidelines adviced the use of transesophageal Doppler to monitor fluid balance for major operations as central venous pressure monitoring can be inaccurate only used for inotorpes administration in ICU or for induction therapy intake .
Early decatheterization reduced infection risk for those vulnerable patients and enhanced early recovery.
Nursing care is crucial in the preoperative education and
postdischarge follow-up.
Conclusion
ER program has multiple advantages to the patient and the NHS from multiple aspects.
– Level of evidence is III as this is a case control study
– ER is a beneficial program requiring involvement of multidisciplinary team in a systematic well organised approach including preoperative ,operative , postoperative and discharge follow up periods .
ER is a rehabilitation program after centered on a multimodal recovery pathway to reduce postoperative pain and to accelerate recovery
The aims :
** To make patients are active participants in their own recovery process
** ensure that patients always receive
** evidence-based care at the right time.
** reduces the length of hospital stay
** fast track and accelerated rehabilitation
264 consecutive renal transplant patients. 135 patients went through the ER program 151 patients who had traditional recovery.
Patient education and discharge planning were commenced on admission.
For living-donor recipients (66%) received carbohydrate
For deceased-donor recipients (46%) received carbohydrate
All diabetic patients were excluded
Intraoperative anesthetic care included fluid therapy using transesophageal Doppler to achieve adequate fluid balance and to avoid the use of central lines. Central lines were only used when
● inotropic support was required
● thymoglobulin induction
● Intrathecal diamorphine to improve the postoperative analgesia during the first 24 hours after surgery.
● Free oral intake was commenced a few hours after the operation, allowing discontinuation of intravenous fluid replacement within the first 24 hours after surgery.
● Early mobilization was encouraged from the first postoperative day, allowing patients to sit on a chair for 2 hours.
● Laxatives and oral analgesia were also commenced on the first postoperative day. Urinary catheters were removed 2 to 6 days after transplant (average of 4 days). ● Wound drains, if used, were removed within the first 48 hours of surgery unless it was productive.
Results
** There were no differences in patient characteristics (age, sex, type of donor, and number of renal grafts received) between the ER group and the traditional recovery group
The postoperative morphine PCA requirement was reduced in the ER group compared with the traditional recovery group
** There were no significant differences in the oral analgesia requirement between the 2 groups
** excellent patient satisfaction with early mobility and oral intake in ER vs traditional recovery
Discussion
ER program is a multidisciplinary, evidence-based approach that benefits both patients by improving their care and also the NHS by reducing the workload on the medical staff and cost of treatment.
We found
** reduced PCA morphine requirements
** reduced lengths of hospital stay, and
** reduced readmission rates in association
** excellent patient satisfaction.
** improved quality of care
Preoperative patient counseling in association with good education is paramount for success of the program.
** it is valuable in enhancing recovery in ESRD patients and may counteract the postoperative hyperkaliemia due to its CHO content.
The National Institute for Health and Care Excellence Guidelines in 2012 recommended the use of transesophageal Doppler to monitor fluid balance in patients who had a major operation.
Central venous pressure monitoring can be inaccurate and even inappropriate to guide the fluid therapy.
This evaluation has a number of limitations It involved a historical control group
** length of stay was accurately recorded in the hospital database.
** Morphine requirements of the control group were available for only some patients
** CHO drinks were not given to all nondiabetic patients
The satisfaction survey included only the last 25 patients
** nursing care is hugely important
** ER does not only improve the quality of care of renal transplant patients but also provides other patients with advantages by reallocating the nursing and medical staff to look after critically ill patients
Level of evidence ( case control studies ) Ievel III
We implemented the ER in our work place by
1 – formation MDT ( nephrologist , cardiologist , Anesthesiologist , Dietitian , nursing team , surgeon )
2 – Discussing protocols for ER programs
3 – patient education before admission
We haven’t got a satisfactory reply in regards to the question,
‘what level of evidence does this study provide?’
Dear Dr Sharma,
This is a prospective non-randomized cohort study which makes it level 2 evidence
Briefly summarise this article highlighting the principal elements of enhanced recovery in renal transplant recipients.
This article explains the principal elements of enhanced recovery in kidney transplant patients very nicely. It quite noval for physicians like us practicing in developing countries. Simultaneously, its also not easy for us to implement such stringent programs at our workplace settings. These principal elements are as follows.
What is the level of evidence provided by this article?
Since , the control group was a historical group without randomisation, it falls in level 4 evidence.
How would you implement enhanced recovery in your workplace?
As mentioned above it will not be an easy task to implement this program in my workplace but it is very worth to give a try. the biggest hurdle at my workplace will be as follows:
Thank you for the summary; well done.