1. Colorectal Enhanced Recovery - Anaesthetic Quick Reference Card
Theatre
Epidural
• Epidural for all cases including laparoscopic unless contraindicated or refused. Site at appropriate thoracic
dermatome e.g. T9-10 right hemicolectomy, lower for AP resection.
• Pump comes with patient from ward. Codes are 700 (set rate) and 855 (for bolus)
Induction
• As deemed appropriate (for rapid recovery) by anaesthetist.
Maintenance
• O2/Air mix & ensure FiO2 ≥ 80%. Desflurane (Sevo if unavailable) or TIVA with propofol/remifentanil.
Analgesia
• Establish block with low-dose mix (LDM) or 0.25% bupivacaine. Ideally run LDM intra-op, or use remifentanil
(if so, establish epidural block BEFORE arrival in recovery)
• IV Paracetamol in theatre & prescribe postop. IV Diclofenac unless C/I or pre-op renal impairment.
Antiemesis
• IV Ondansetron + IV dexamethasone & prescribe postop PRN.
Monitoring
• As standard plus Oesophageal Doppler, temperature probe. Arterial / CVC line only if indicated.
Fluids
• Maintenance – Hartmann’s at 5 ml kg-1 hr-1. Bolus – Gelofusine 250ml. Keep Hb ≥ 8.0 g/dl.
Optimise Stroke Volume (SV) with oesophageal doppler
• Give discrete 250ml bolus and if SV shows ≥10% rise, repeat until SV no longer rises by 10%. Do not give
further bolus unless SV falls or patient loses blood volume. Document SV & response to boluses on
anaesthetic chart.
• Hypotension is likely when epidural used intraoperatively. Corrected Flow Time (FTc) is likely to be high
(>360ms). If hypotension persists after optimisation of SV use vasoconstrictor by bolus or infusion. Consider
inotropes if Peak Velocity (PV) low and the clinical picture is suggestive of poor ventricular function.
Temperature
• Fluid warmer and hot air blanket for all patients. Do not remove hot air blanket until leaving theatre.
Transfer
• Epidural pump attached and running. Warn recovery and obtain ‘trauma’ mask (mask with non-rebreath
reservoir bag). Use at 15l/min flow to deliver FiO2 ≥ 80% for transfer.
• Send hot air blanket round with patient if temp <360 C.
Recovery
Respiratory
• High flow O2 via ‘trauma’ mask for 2 hrs irrespective of saturations. After 2 hrs, O2 via nasal cannulae only if
needed to maintain SpO2% ≥ 95%.
Circulation
• Keep MAP ≥ 65mmHg. 250ml Gelofusine and anaesthetic review if BP low.
Fluids
• Oral fluids ASAP. Hartmann’s 2 ml kg-1 hr-1 until drinking.
Mobilisation
• Give oral ephedrine 30mg ½ hour prior to sitting out if epidural in situ
• Sit out in chair for ≥ 15 mins before leaving recovery. Watch for hypotension – 250 - 500ml fluid bolus and
medical review if it occurs.
Discharge
• If stable after sitting out in chair.
Version 2 November 2006 Page 1 of 1