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Enhanced Recovery Protocols


Enhanced Recovery principles and protocols are now considered to be a standard of care in many surgical specialties. These include colorectal, endocrine, gynaecological, urological, vascular and orthopaedic surgery, with further studies adding to the list.

ODM and Enhanced Recovery

Intraoperative Fluid Management using oesophageal Doppler monitoring is a vital element of Enhanced Recovery and has been well validated within the accepted protocol. In the UK, it is supported by the  Enhanced Recovery Partnership in line with the National Institute of Clinical Excellence (NICE) Guidance MTG3, the NHS Operating Framework 2012/13 and the Department of Health Innovation Health and Wealth Review, 2011.

In Europe, ODM was chosen by the Enhanced Recovery After Surgery (ERAS) group, stating that ‘Oesophageal Doppler ultrasonography was chosen as the preferred method of monitoring intraoperative stroke volume due to the broader evidence base in this context’.

Which patients?

The following list identifies the surgical patients who should receive ODM, as recommended by the Enhanced Recovery Partnership:

  • Major surgery with a mortality rate of >1%.
  • Major surgery with an anticipated blood loss of greater than 500mls.
  • Major intra-abdominal surgery.
  • Intermediate surgery in high-risk patients, including patients aged >80 years.
  • Unexpected blood loss and/or fluid loss requiring >2 litres of fluid replacement.
  • Patients with ongoing evidence of hypovolaemia and/or tissue hypoperfusion.

Professor Monty Mythen, Clinical Lead for the Department of Health’s Enhanced Recovery Partnership Programme & Professor of Anaesthesia & Critical Care at University College London said:

“I have worked with ODM for almost two decades and have seen the benefits in my patients.”

“By offering a much less invasive method of fluid management during and after surgery, ODM helps patients recover more quickly.  I am delighted that this guidance has highlighted the advantages of this technology, and I hope that it gives the NHS the impetus it needs to ensure better access for all.”

Download Enhanced Recovery brochure using ODM

Enhanced Recovery Recommendations

‘The concept of “goal-directed fluid therapy” has evolved and requires individualized pre- and postoperative optimization of stroke volume determined by providing small challenges of colloid and assessing cardiac function by the esophageal Doppler.’
Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery, H. Kehlet and DW. Wilmore.

‘Minimally invasive cardiac output monitors such as the oesophageal Doppler (OD) device target fluid on an individualised basis by challenging the patient with a fluid bolus (e.g., 200 ml colloid) and seeing if there is an increase in stroke volume of >10 %. This fluid challenge is repeated every 10–15 min until there is no further increase in stroke volume. At this point, the stroke volume is ‘‘optimised’’. A meta-analysis of the use of OD to target fluid therapy in major surgery has demonstrated LOSH, fewer complications, faster return of bowel function, reduced infection rates, less nausea and vomiting, a lower incidence of acute kidney injury, and the possible improvement of survival after surgery.’
Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. UO. Gustafsson, MJ. Scott, W. Schwenk, N. Demartines, D. Roulin, N. Francis, CE. McNaught, J. MacFie, AS. Liberman, M. Soop, A. Hill, RH. Kennedy, DN. Lobo, K. Fearon, O. Ljungqvist.

Fluid Balance, Near-zero fluid balance, avoiding overload of salt and water results in improved outcomes. Perioperative monitoring of stroke volume with transoesophageal Doppler to optimizecardiac output with fluid boluses improves outcomes. Balanced crystalloids should be preferred to 0.9 % saline.
Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS) Society Recommendations, Kristoffer Lassen, Marielle M. E. Coolsen, Karem Slim, Francesco Carli, Jose E. de Aguilar-Nascimento, Markus Schafer, Rowan W. Parks, Kenneth C. H. Fearon, Dileep N. Lobo, Nicolas Demartines, Marco Braga, Olle Ljungqvist, Cornelis H. C. Dejong.

Summary and recommendations:
Fluid balance should be optimised by targeting cardiac output and avoiding overhydration.  Judicious use of vasopressors is recommended with arterial hypotension. Targeted fluid therapy using the oesophageal Doppler system is recommended.
Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations.

‘The Enhanced Recovery Partnership fully supports the use of intra-operative fluid management technologies to deliver individualised goal directed fluid therapy. This is recommended in the 2012-13 NHS Operating Framework1, in the Innovation, Health and Wealth Review and in NICE Guideline MTG3′. NICE guidelines MTG3 are specifically for the CardioQ-ODM oesophageal Doppler Monitor.  ERPP document
Enhanced Recovery Partnership Program. Fulfilling the potential. A better journey for the patients a better deal for the NHS.

‘Preload optimization guided by stroke volume, as measured by oesophageal Doppler ultrasonography, was almost always associated with a significant reduction in length of hospital stay and postoperative morbidity. In contrast to these studies, investigations based on the measurement of stroke volume by the Vigileo™ monitor/FloTrac™ sensor (Edwards Lifesciences, Irvine, CA, USA) or by the lithium indicator dilution cardiac output (LiDCO™; Lidco, Cambridge, UK) system did not uniformly improve outcome. ERAS Recommendation ‘Oesophageal Doppler ultrasonography was chosen as the preferred method of monitoring intraoperative stroke volume due to the broader evidence base in this context.’
Development and Feasibility Study of an Algorithm for Intraoperative Goaldirected Haemodynamic Management in Noncardiac Surgery, A Feldheiser, P Conroy, T Bonomo, B Cox, T Ruiz Garces and C Spies, on behalf of the anaesthesia working group of the Enhanced Recovery After Surgery Society (ERAS).

Peri-operative fluid management:
‘Both fluid excess or hypovolemia can provoke splanchnic hypoperfusion, which can then result in ileus, increased morbidity and LOS. While goal directed fluid therapy (GDFT) using esophageal Doppler to achieve “near maximal stroke volume” has been recommended in rectal surgery,these protocols have often been compared to obsolete regimens with either fluid overload or unwarranted restriction.’
Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS) society recommendations, Yannick Cerantola, Massimo Valerio, Beata Persson, Partrice Jichlinkski, Olle Ljungqvist, Martin Hubner, Wassim Kassouf,  Stig Muller, Gabriele Baldini, Francesco Carli, Torvind Naesheimh, Lars Ytrebo,  Arthur Revhaug, Kristoffer Lassen, Tore Knutsen, Erling Aarsether, Peter Wiklund, Hitendra R.H. Patel.

Oesophageal Doppler-guided SV optimisation during surgery was one component of the enhanced recovery protocol implemented across twelve Spanish hospitals in this study. The application of enhanced recovery “shortens hospital stay and reduces morbidity after colorectal resection compared with conventional care. Additional benefits can be achieved by using a laparoscopic approach with these patients.” A multicentre comparison of a fast track or conventional postoperative protocol following laparoscopic or open elective surgery for colorectal cancer surgery.  F. Esteban, FJ. Cerdan, M. Garcia-Alonso, R. Sanz-Lopez, A. Arroyo, JM. Ramirez, C. Moreno, R. Morales, A. Navarro and M. Fuentes.

Further Recommendations and protocols can be found here: Fast-Track Surgery