Introduction Liver resection offers curative treatment to a number of malignant conditions. It has traditionally been associated with poor post-operative outcomes. More recently a mortality rate of less than five per cent has become established but morbidity remains high. Enhanced Recovery After Surgery (ERAS) has become established practice in a number of surgical specialties and has shown improvement in post-operative outcomes. ERAS has been introduced for liver resection however practice is less well established and liver surgery has several complexities that need to be accommodated in order to optimise post-operative care. The following thesis aims to identify areas that require clarification and investigate peri-operative care components to establish optimum practice. Methods Systematic review and meta-analysis were performed to identify areas that required clarification and were lacking in sufficient evidence to guide practice. A randomised controlled trial was performed to compare established areas of practice. Prospective observational studies were performed when exploratory investigation was required. Retrospective analysis of a prospectively collected database was performed to identify risk factors for post-operative morbidity. Patients included in the above trials underwent liver resection at the Royal Infirmary of Edinburgh, UK, between December 2012 and August 2014. Results Post-operative analgesia after liver resection was identified as being an area that was controversial. Continuous wound infiltration was shown to offer improved recovery times when compared to epidural with no significant associated disadvantages. After retrospective review of 603 liver resections, extended resection was observed to be associated with high morbidity rates. It was hypothesised that post-operative nutritional requirements might be higher in these patients. This was not found to be the case but post-operative energy requirements were found to be difficult to predict after liver resection, suggesting the benefits of real-time monitoring of energy expenditure. Finally acetaminophen metabolism was suspected of being altered after major resection. An observational study suggested that despite altered metabolism, glutathione deficiency was not observed after major resection and so liver volume was not a contra-indication to acetaminophen administration. Summary Liver resection offers a complex set of conditions on which to base an enhanced recovery protocol. Current ERAS literature does not completely address these issues. This thesis has investigated several aspects of care unique to liver surgery in an attempt to optimise peri-operative care and improve post-operative outcome after liver surgery.

The purpose of this project was to evaluate the effectiveness of adopting clinical care bundles for the enhanced recovery program (ERP) at the project site. The practice-focused questions explored whether care bundles from the enhanced recovery program (ERP) would achieve positive postoperative patient care experiences when compared to the traditional surgical care pathways. The concepts, models, method, and theories used for this project include the Iowa model, the plan-do-study-act model, lean methodology, Donabedian's framework, and Watson's theory of caring. The sources of evidence included the facility site analysis report to evaluate surgical inpatient complications, morbidity, and mortality rates. Over 100 items related to surgical postoperative inpatient details were retrieved from the facility site database. Using descriptive analysis of 31 postoperative surgical inpatients' demographics, body mass index data, 30-day readmission, and comorbidities, the findings indicated that the ERP is an efficient, cost-effective program with positive postoperative inpatient outcomes in comparison to traditional surgical care pathways. The impact of the evaluation of the ERP predominately improves patient outcomes, which is a positive social change to postoperative inpatients, families, clinical staff, and the project site operational and clinical performance. The implications of this study for nursing practice and positive social change include standardization of quality and patient safety in a dynamic healthcare environment.

Class of 2017 Abstract / Objectives: To determine if the addition of oral alvimopan, liposomal bupivacaine and intravenous acetaminophen as part of a comprehensive enhanced recovery after surgery (ERAS) program decreases length of stay, recovery time and narcotic/acetaminophen use without affecting colorectal surgery patient outcomes. Methods: Patients were compared before and after the implementation of alvimopan, liposomal bupivacaine and intravenous acetaminophen with an ERAS program. The primary outcome was hospital length of stay (measured in hours). Secondary outcomes included change in time to first meal, bowel sounds, and bowel movement (measured in hours), pain scores (visual analog scale 0-10), opioid use (measured in morphine equivalent milligrams), and acetaminophen use (measured in mg). Results: Thirty-seven individuals were included in the pre implementation population and fifty one patients were included in the post implementation population. The mean length of stay decreased from 124.3 hours to 100.2 hours (P equals 0.13) with the addition of the ERAS program with the three medications. The 24 hour morphine equivalent intervals for seventy-two hours following surgery decreased from 125.8 mg (day 1), 81.9 mg (day 2) and 44.5 mg (day 3) to 44.3 mg (day 1), 22.8 mg (day 2) and 13.2 mg (day 3) (P less than 0.005 for each one). Conclusions: The addition of alvimopan, liposomal bupivacaine and intravenous acetaminophen as part of a comprehensive ERAS program decreased length of stay but not significantly. However, the addition of these three medications with the ERAS program changes was associated with a statistically significant decrease in opioid use.

Class of 2017 Abstract / Objectives: To determine if the addition of oral alvimopan, liposomal bupivacaine and intravenous acetaminophen as part of a comprehensive enhanced recovery after surgery (ERAS) program decreases length of stay, recovery time and narcotic/acetaminophen use without affecting colorectal surgery patient outcomes. Methods: Patients were compared before and after the implementation of alvimopan, liposomal bupivacaine and intravenous acetaminophen with an ERAS program. The primary outcome was hospital length of stay (measured in hours). Secondary outcomes included change in time to first meal, bowel sounds, and bowel movement (measured in hours), pain scores (visual analog scale 0-10), opioid use (measured in morphine equivalent milligrams), and acetaminophen use (measured in mg). Results: Thirty-seven individuals were included in the pre implementation population and fifty one patients were included in the post implementation population. The mean length of stay decreased from 124.3 hours to 100.2 hours (P equals 0.13) with the addition of the ERAS program with the three medications. The 24 hour morphine equivalent intervals for seventy-two hours following surgery decreased from 125.8 mg (day 1), 81.9 mg (day 2) and 44.5 mg (day 3) to 44.3 mg (day 1), 22.8 mg (day 2) and 13.2 mg (day 3) (P less than 0.005 for each one). Conclusions: The addition of alvimopan, liposomal bupivacaine and intravenous acetaminophen as part of a comprehensive ERAS program decreased length of stay but not significantly. However, the addition of these three medications with the ERAS program changes was associated with a statistically significant decrease in opioid use.

Bakgrund: Enhanced Recovery After Surgery (ERAS) är ett vårdprogram skapat för att förbättra återhämtning och minska kroppens stresspåslag efter kirurgi. Det första ERAS- programmet utvecklades år 2012 för kolorektalkirurgi.  Kolorektalcancer drabbar ca 6 400 personer/år i Sverige, och ca 2 600 personer dör årligen. Detta gör det till en av de vanligaste cancerformerna, och den behandlas med kirurgi. Fler och fler sjukhus vårdar patienter, med denna typ av cancer, enligt vårdprogrammet ERAS. Det har visat sig att det har gett patienter en kortare vårdtid, färre komplikationer och i och med detta blir kostnaderna inte lika höga. Syfte: Syftet är att beskriva patienters upplevelse av att vårdas enligt ERAS vid kolorektalkirurgi. Metod: En litteraturöversikt baserat på 10 empiriska studier. Databaserna PubMed och CINAHL användes vid datainsamlingen. Virginia Hendersons omvårdnadsteori utgjorde litteraturöversiktens teoretiska referensram. Resultat: Fem teman identifierades som beskrev patienternas upplevelse av ERAS vid kolorektalkirurgi. Dessa teman var: information, vårdpersonalens bemötande, delaktighet i sin egen vård, nutrition och vårdmiljö. Resultatet visar att mer information behövs och att både informationen och vården måste vara individanpassad. Slutsats: Patienterna upplever inte att ERAS individanpassar informationen vilket gör den svårförstådd och ger en känsla av att inte ha kontroll. Programmet skulle behöva göra individanpassningar för att passa alla typer av patienter och för att kunna ge patienterna möjlighet till att vara delaktiga i sin vård. Genom att vårdpersonal får en ökad förståelse för patienternas upplevelser kan vårdprogrammet förbättras.

Advances in surgical technique and medical management have led to fundamental changes in surgical care allowing for a paradigm shift from inpatient to outpatient surgery. Enhanced recovery pathways have moved surgical recovery from inpatient to outpatient settings requiring informal caregiver support. The purpose of this study was to determine the prevalence of caregiver burden in this patient population and to explore whether caregiver burden contributes to preventable use of emergency room services. The conceptual framework supporting this retrospective cross-sectional study was Andersen's behavioral model of health services utilization. Data collected from 28 urologic patient/caregiver pairs were analyzed using descriptive statistics and linear and logistic regression. Findings indicated measurable caregiver burden in 2 of the 5 Caregiver Reaction Assessment (CRA) subscales: impact on schedule and impact on health. Findings also indicated a measurable protective effect of high socioeconomic status of caregivers and the CRA subscale of impact on finances, and a possible protective effect of caregiver self-esteem as measured by the CRA subscale and emergency room utilization within the first 30 days after enhanced recovery surgery. Social change implications include improving the surgical experience of patients and caregivers and enhancing the use of health care resources.

Bakgrund: Inom kolorektalkirurgi är ”Enhanced Recovery After Surgery” (ERAS) ett standardiserat koncept pre-, intra- och postoperativt som syftar till snabb återhämtning efter operation. För att nå goda resultat i den postoperativa vården, där tidigt nutritionsintag och tidig mobilisering är viktiga faktorer, har patientens delaktighet visat sig vara viktig. För att utveckla omvårdnaden postoperativt och bland annat förbättra tidig mobilisering och tidigt nutritionsintag behöver de faktorer som påverkar patientdelaktigheten identifieras. Syfte: Att beskriva patienternas erfarenheter av den postoperativa vården efter genomgången kolorektalkirurgi enligt ”Enhanced Recovery After Surgery” med fokus på patientdelaktighet. Metod: Semistrukturerade intervjuer genomfördes med personer som genomgått kirurgi enligt ERAS (tio deltagare). Kvalitativ innehållsanalys användes som analysmetod. Resultat: Personerna ansåg sig vara välinformerade före operation och tyckte att de fått förståelse för konceptet, dock upplevdes loggbokens funktion vara otydlig. Alla patienter var nöjda med tiden på vårdavdelningen och resultatet visade att relationen mellan patient och vårdpersonal hade stor betydelse för återhämtningen postoperativt. Att upprätthålla god nutrition var dock en utmaning då många patienter upplevde illamående och hade svårt att äta samt dricka näringsdrycker.  Slutsats: ERAS-konceptet bidrar till trygghet för patienten genom kontinuitet och tydliga riktlinjer vilket möjliggör delaktighet och stimulerar till återhämtning efter operation. Personer med ett försvagat fysiskt utgångsläge har dock ett större behov av personalens stöttning och ett personcentrerat förhållningssätt skulle möjliggöra en individuellt anpassad vård utifrån ERAS-konceptet. Majoriteten av patienterna besväras dock av illamående postoperativt vilket har negativ påverkan på patientens återhämtning men också på upplevelsen som helhet, detta problem behöver ses över närmre för att om möjligt förbättras. / Background: In colorectal surgery ”Enhanced Recovery After Surgery” (ERAS) is a standardized pre-, intra- and postoperative concept aiming to enhance recovery after surgery. To achieve good outcome in postoperative care, early nutritional intake and early mobilisation has been identified as important factors as well as the patient´s involvement in their care. In order to develop postoperative nursing care and improve early mobilisation and early nutritional intake, factors affecting patient participation need to be identified. Aim: To describe patients experiences of the postoperative care after colorectal cancer surgery according to ”Enhanced Recovery After Surgery” with a specific focus on patient participation.   Method: Semi structured interviews were conducted with individuals undergoing surgery according to ERAS (ten participants). The interviews were analysed using a qualitative content analyze method. Result: The individuals considered themselves well informed before surgery and thought they understood the concept, but the logbook´s function was found to be unclear. All patients were satisfied with the time in the surgical care department and the results showed that the relationship between the patient and healthcare staff are of great importance for postoperative recovery. Maintaining good nutrition postoperatively, however, is a challenge when many patients experienced nausea and had difficulty eating and drinking nutritional beverages.  Conclusion: The ERAS concept contributes patient safety through continuity and clear guidelines, enabling participation and stimulating postoperative recovery. People with a weakened physical starting position, however, have a greater need for staff support and a person-centred approach would enable that, based on the ERAS concept. However the majority of patients suffer from postoperative nausea which has a negative impact on patient recovery but also on the experience as a whole, this problem has to be reviewed closer, but also improved if possible.

Bakgrund: ERAS (Enhanced Recovery After Surgery) är ett standardiserat multimodalt vårdprogram vid elektiv kolorektalkirurgi, som syftar till snabbare återhämtning och kortare vårdtider genom ett tvärprofessionellt samarbete.  En vecka innan planerad operation träffar sjuksköterskan patienten för ett samtal om vårdförloppet.   Syfte: Att identifiera och beskriva patientens upplevelse av sjuksköterskans ERAS- samtal och dess betydelse för patientens delaktighet i sin vård.    Metod: Datainsamlingen skedde genom kvalitativa intervjuer. Tolv patienter, nio män och tre kvinnor har intervjuats. De ljudinspelade samtalen har transkriberats ordagrant och analyserats med hjälp av tolkande fenomenologisk analys (Interpretative Phenomenological Analysis).   Resultat: Analysarbetet resulterade i fem olika teman; bli sedd, trygghet, tillit, ansvar samt delaktighet. Alla teman relaterar till varandra och illustrerar en positiv och en negativ sida av den upplevda erfarenheten. Tillsammans bildar en helhet av upplevelsen; ERAS- samtalet och dess betydelse för patientens delaktighet.   Konklusion: Resultatet visar att patienterna känner sig sedda under informationssamtalet. Det är viktigt att bekräfta patienten och knyta an mer till informationssamtalet under vårdtiden för att patienterna ska vara delaktiga och ta eget ansvar. Tilliten till vårdpersonalen har betydelse för att patienterna ska känna trygghet. Studien visar att ERAS- samtalet upplevs strukturerat och individuellt men informationen måste följa patienterna under hela vårdtillfället.

The opioid epidemic is a public health crisis in the United States that impacts the lives of millions of people. There is a need for interventions aimed at minimizing opioid usage in clinical settings. The perioperative care period – consisting of the time before, during, and after surgery – is a time where interventions can be made in surgical and anesthesia practice to reduce the number of opioids used. Surgery and anesthesia are two areas where patients have traditionally been introduced to prescription opioids for the first time. Enhanced Recovery After Surgery pathways have been designed to integrate and improve surgical care for patients resulting in decreased length of stay in the hospital for surgical patients. Enhanced Recovery After Surgery pathways have also explored reducing opioid use during surgical care. Multimodal Analgesia and Opioid Free Anesthesia are two methods that have been researched and shown to be successful in limiting the perioperative use of opioids. Multimodal Analgesia and Opioid Free Anesthesia both reduce total perioperative opioid use and manage pain as effectively as opioids.

Bakgrund: Kolorektal kirurgi är en operation som ger en lång återhämtningstid för patienten. Enhanced Recovery After Surgery, är ett snabbt återhämtningsprogram som gör att patienter kan återhämta sig bättre från operationen och därmed skrivas ut från sjukhuset och komma hem betydligt mycket snabbare än med standard återhämtningsprogram. Syfte: Syftet med studien var att beskriva upplevelsen av återhämtning med ERAS efter kolorektal kirurgi. Metod: En kvalitativ innehållsanalys med manifest ansats användes för att analysera 14 vetenskapliga artiklar som inkluderades i studien. De vetenskapliga artiklarna valdes ut från sökoperatörerna Cinahl och Pubmed för att sedan granskas med LTU’S kvalitetsgranskningsmall. Resultatet: Analysen presenteras i fem slutkategorier som beskriver patienters upplevelse av återhämtning med ERAS efter kolorektal kirurgi: ”Att få information vid ERAS” ”Att följa ERAS-programmet var påfrestande” ”Svårigheter att följa rekommendationen att äta postoperativt” ”Att känna delaktighet och stöd i sin återhämtning””Att erfara tidig utskrivning” Slutsats: Resultatet i studien visade att många patienter upplevde återhämtningen som krävande. De fick för lite information kring omvårdnaden samt hade det svårt med den tidiga mobiliseringen på grund av smärta och fysisk maktlöshet. Det snabba näringsintaget efter operationen var även ett hinder då illamående och rädsla av att belasta tarmen för snabbt fanns. Patienterna upplevde det positivt med stöd av anhöriga och vårdpersonal och när dem fick känna sig delaktiga i sin egen återhämtning. Resultatet i studien kan användas för en vidare kunskap om hur det är att genomgå ERAS-programmet vid kolorektal kirurgi samt för att vårdpersonal skall kunna ge en sådan bra och personcentrerad omvårdnad som möjligt.