Enhanced Recovery after your emergency operation - colorectal surgery

Your estimated discharge date

The Enhanced Recovery Nurses will discuss your estimated discharge date with you.

Introduction

This information aims to increase your level of understanding of how you can play an active part in your recovery, after your emergency surgery. If there is anything that you are unsure about, please ask. It is important that you understand how you can help yourself recover, so that you, your family and friends can be involved.

Enhanced Recovery is a programme offered by North Bristol NHS Trust for patients undergoing emergency bowel surgery. Having surgery as an emergency can be stressful, and this information will help your recovery.

What is Enhanced Recovery?

The aim of Enhanced Recovery is to get you back to full health as quickly as possible after your operation.

Research indicates that after surgery, the earlier we get you out of bed, exercising, eating and drinking, your recovery will be quicker and it will be less likely that complications will develop.

Some of the benefits include:

A quicker return of normal bowel function.
Reduced chest infections.
A quicker return to usual mobility.
Decreased fatigue.
Reduced risk of developing blood clots after surgery.

In order to achieve this we need you to be partners with us, so that we can work together to speed up your recovery.

Before your surgery

There is evidence to suggest that keeping warm, before surgery, helps prevent infection. Please ensure you have a warm dressing gown or similar item of clothing to wear immediately before your operation.

If possible, please ask a relative or friend to also bring you a supply of comfortable ‘day clothes’ for after your operation. You will be encouraged to return to normality as quickly as possible, and this includes getting dressed.

Eating and drinking

In preparation for your operation, if you are allowed to eat and drink normally, you should aim to take 3 of the Fortisip or Fortijuce supplement drinks per day. The drinks will be supplied by the ward for two days before your surgery.

The supplement drinks are important to help with wound healing, to reduce the risk of infection and aid with your overall recovery. It is important that you also continue to have a variety of other non-fizzy drinks during your hospital stay.

As well as the supplement drinks mentioned, you will also be required to take special carbohydrate drinks called ‘Pre Op’. You will require two drinks the night before and 2 drinks on the day of your operation, three hours before surgery. If your operation is very urgent, you may only be given two ‘Pre Op’ drinks before surgery.

You may continue to eat for up to six hours before your operation and drink fluids for up to three hours before, unless otherwise directed by your doctor.

A few hours after your operation you will start to drink and eat if you wish. It is important that you eat and drink early after your surgery, however if your operation was for a blockage in the bowel, early eating may not be appropriate. The ward staff will help and advise you. You will be expected to recommence the supplement drinks to help build up your strength. The drinks will either be given to you by the ward staff or you can help yourself to the drinks from the patients fridge.

Studies show that chewing gum after an operation can be helpful towards improving your recovery by assisting the bowel to return to its normal function.

Please ask a relative or friend to bring some chewing gum in for you. After your operation chew gum for 15 minutes, three times a day, until your bowel function returns to normal.

Preparing for theatre

On the day of your operation you may be given an enema to empty your bowel contents.

In order to help prevent blood clots you will be required to wear special support stockings (TEDS). The nurse will need to measure your legs to obtain the correct size.

You will also be given a small injection called ‘clexane’ at approximately 6pm each day you are in hospital. This helps reduce the risk of blood clots by thinning the blood.

Some patients who are at higher risk of experiencing blood clots may have to continue with the injection once home. This would only be for a few weeks after surgery and will be fully discussed with you when you are in hospital. Most patients are able to administer the injection themselves or with the help of a relative or carer. The nurses on the ward will show you how to use the injection during your hospital stay. If you have any problems with administering the injection an appointment can be made with your practice nurse to carry this out each day, or we will arrange for a District Nurse to visit you if you are unable to leave the house.

It is important that you keep yourself warm before your operation and you are advised to dress accordingly, (warm dressing gown, socks, slippers, blankets). You will be asked to remove the warm clothing when it is time for your operation as you will be required to wear a hospital gown.

After your operation

Mobilising and exercising

Following your operation when you wake up, it is important that you do deep breathing exercises (as prevention against chest infection). You will need to do 5 deep breathing exercises every hour. To do these you will need to:

Be in an upright position.
Take a deep slow breath in (feel your stomach gently rise).
Hold the breath for 3 seconds.
Breathe out slowly.
Repeat 5 times.

You should cough regularly to make sure your lungs are clear of secretions. To do this, place a towel or pillow over your abdomen and wound. Support it with your hands and cough.

When you are sitting in the chair or lying in bed, you should also do frequent leg exercises, (as prevention against blood clots) pointing your feet up and down and moving your ankles as if making circles can achieve this.

Depending on what time you come back to the ward, the staff will help you out of bed about six hours after your operation. You may sit out of bed for up to two hours on the day of surgery and then up to six-eight hours out of bed on each subsequent day after surgery if you can manage this.

You will be encouraged to walk at least 60 metres four to six times per day after your surgery if you can manage this. By being out of bed in a more upright position and by walking regularly, lung function is improved and there is less chance of a chest infection after surgery. Circulation is also improved, reducing the risk of a blood clots and helping bowel function return to normal.

Try wearing your day clothes as soon as you feel able after your operation as this can help you feel positive about your recovery.

Pain control

It is important that your pain is controlled so that you can walk about, breathe deeply, eat and drink, feel relaxed and sleep well. Please let us know if your pain is not manageable so that we can help you.

It is also important for us to know if you are either allergic or sensitive to certain pain killers.

You may be given one of, or a combination of the following methods of pain relief, to keep you comfortable after surgery:

Patient controlled analgesia (PCA). This is an intravenous pain killing medication, delivered by a machine, which is set up so that you can control it yourself. You will be given instructions on how to do this.
Tap block. This is an injection given at the time of your operation to temporarily numb the abdomen and keep you comfortable immediately afterwards.
Spinal block. This is an injection given at the time of your operation that will temporarily numb you from the waist down and will keep you comfortable afterwards.
Ketamine infusion. This is a continuous intravenous pain killing medication which will run up to 24 hours after surgery.

The anaesthetist may discuss these options with you and explain more about it whilst you are in hospital, before your operation.

Alongside this, the doctors will prescribe other types of pain relieving medicines, which work in different ways. You will be given these regularly (three or four times per day) and you should feel more comfortable.

If the pain worsens at any time, please tell the nursing staff immediately and they will be able to help you.

Sickness

Sometimes after an operation it is not uncommon to feel nauseated and occasionally vomit. You will be given medication during surgery to reduce this, but if you feel sick following surgery please tell a member of staff who will be able to help.

Tubes and drips

During your operation a tube (catheter) will be placed into your bladder so that we can check that your kidneys are working well and your urine output can be measured. This tube will be removed as soon as possible.

You will have an intravenous drip put into your arm to ensure you do not become dehydrated. The drip will normally be removed the day after surgery, but you may still have the intravenous port (venflon) in place for a couple of days in case we have to give other drugs through it.

It is possible you may return from your surgery with a tube in your nose. The tube may stay in a few days which will help drain your stomach if your surgery was due to a blockage or an emergency. We aim to remove the tube as soon as possible. Please wait until the tube is removed before trying to eat. Staff can advise.

You may also be required to breathe extra oxygen for a short while after your operation.

Monitoring

Many different things will be monitored during your treatment including:

Observations (blood pressure, pulse, temperature).
Fluid in.
Fluid out.
Food eaten.
When your bowel first starts working or you pass wind.
Pain assessment.
Number of walks achieved.
Time spent out of bed.

You may be asked to tell us about what you eat and drink and what you pass so that we can record it.

Whilst you are in hospital you will be asked to participate in maintaining a daily diary / log (provided by the ward), so that you can keep a record of how well you are managing. This will help us monitor your progress.

Please remember playing an active part in your recovery will help you get better sooner. If you have any questions regarding your recovery please do not be afraid to ask a member of staff.

References and further information

For further information on the Enhanced Recovery Programme you may access the following websites:

www.nbt.nhs.uk/erp
www.gov.uk/government/organisations/department-of-health-and-social-care

How to contact us

Brunel building
Southmead Hospital
Bristol BS10 5NB

Surgical Admissions Unit
Gate 32B
Telephone: 0117 414 3233

Enhanced Recovery Nurses
Telephone: 0117 414 3610
Telephone: 0117 414 3611

Colorectal nurses
Telephone: 0117 414 0514

Stoma Care Nurses
Telephone: 0117 414 0270