How would my patient be after this surgery??? What can I do to make my patient safe & get well soon?!?

How would my patient be after this surgery???

What can I do to make my patient

safe & get well soon?!?

VS

Traditional Peri-operative Care

• Poor counseling • Starved • Drowned• Stressed • Poor analgesia • Enforced bed rest• Long hospital stay

Multi-model Strategies• Anxiety/Fear• Organ dysfunction• Hypothermia• Nausea, vomiting,

ileus, semi- starvation • Hypoxemia• Sleep disturbance• Drains, NG tubes,

catheters

• Patient info• Optimise nutrition• Modify alcohol/smoking• Neuraxial blockade• Laparoscopic surgery• Normothermia• Nausea and ileus

prevention• Early enteral feeding• Undisturbed sleep• Opiate sparing analgesia

Del

ayed

Acce

lera

ted

Adapted Luff, 2003

Func

tiona

l cap

acity

Surgery

Multi-modal intervention

Traditional care

Preop WeeksTime

Days

Adapted Luff, 2003

Optimal pain relief

Perioperative fluid restriction

Early enteral nutrition

Early postoperative mobilization

Minimal use of tubes, drains, and catheters

Reduce:• stress

response• organ

dysfunction

Accelerated convalescence

Reduction of overall complications

Shorter hospital stay

Increased patient comfort

Modified W. Schwenk und J.M. Müller, 2005

Enhance

E R A S

RecoveryAfter

Surgery

Preadmission counseling

Selective bowel-prep

Short fasting/CHO- loading

No premed

No NG tubes

Thoracic epidural anesthesia

Short-acting anesthetic agents

Avoidance ofSodium/fluid

overload

Short incisions/surgical technique

Warm air bodyheating in

theatre

Standard mobilization

Non-opial oralanalgesics/NSA IDs

Prevention of nausea and vomiting

Stimulation of gut mobility

Early removal ofcatheters/drains

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Core Protocol

Thromboembolic prophylaxis

Antimicrobial prophylaxisResume Normal Activity Sooner!!

Counseling

Preadmission counseling

Selective bowel-prep

Short fasting/CHO- loading

No premed

No NG tubes

Thoracic epidural anesthesia

Short-acting anesthetic agents

Avoidance ofSodium/fluid

overload

Short incisions/surgical technique

Warm air bodyheating in

theatre

Standard mobilization

Non-opial oralAnalgesics/NSA IDs

Prevention of nausea and vomiting

Stimulation of gut mobility

Early removal ofcatheters/drains

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Core Protocol

Thromboembolic prophylaxis

Antimicrobial prophylaxis

Preoperative Bowel Preparation

Selective bowel-prep

Short fasting/CHO- loading

No premed

No NG tubes

Thoracic epidural anesthesia

Short-acting anesthetic agents

Avoidance ofSodium/fluid

overload

Short incisions/surgical technique

Warm air bodyheating in

theatre

Standard mobilization

Non-opial oralAnalgesics/NSA IDs

Prevention of nausea and vomiting

Stimulation of gut mobility

Early removal ofcatheters/drains

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Core Protocol

Thromboembolic prophylaxis

Antimicrobial prophylaxis

Preoperative Fasting

There was no evidence to suggest a shortened fluid fast results in an increased risk of aspiration,

regurgitation or related morbidity compared with the standard ’nil by mouth from midnight’ fasting

policy.

Response to Surgery and FastingSurgery Fasting

Endocrine response• Glucagon • Insulin

Metabolic response• Glycogen breakdown • Protein breakdown • Lipolysis

Insulin resistance

Fasting further increases metabolic response to surgery

Insulin resistance is a useful metabolic marker

Preoperative Carbohydrate Loading

Preoperative Carbohydrate Loading

- Attenuate stress response - Improve insulin resistance- Reduce recovery time

Short fasting/CHO- loading

No premed

No NG tubes

Thoracic epidural anesthesia

Short-acting anesthetic agents

Avoidance ofSodium/fluid

overload

Short incisions/surgical technique

Warm air bodyheating in

theatre

Standard mobilization

Non-opial oralAnalgesics/NSA IDs

Prevention of nausea and vomiting

Stimulation of gut mobility

Early removal ofcatheters/drains

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Core Protocol

Thromboembolic prophylaxis

Antimicrobial prophylaxis

Premedication

• Avoid long-acting agent • Benzodiazepine(Short-acting: Midazolam)• Beta-Blocker• Alpha2-agonist

Premedication

• Beta-Blockers

– ↓circulating catecholamine

– ↓perioperative cardiovascular events

– ↑hemodynamic stability

– ↑faster emergence & ↓postoperative side effects

– ↑facilitate the resumption of normal activities

Premedication

• Alpha2-agonist

– ↓the use of opioid analgesics, PONV and

intraoperative blood loss

– ↓ the duration of paralytic ileus (IV clonidine +

Epidural clonidine)

– ↑facilitate glycemic control

– ↓reduce myocardial ischemia

No premed

No NG tubes

Thoracic epidural anesthesia

Short-acting anesthetic agents

Avoidance ofSodium/fluid

overload

Short incisions/surgical technique

Warm air bodyheating in

theatre

Standard mobilization

Non-opial oralAnalgesics/NSA IDs

Prevention of nausea and vomiting

Stimulation of gut mobility

Early removal ofcatheters/drains

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Core Protocol

Thromboembolic prophylaxis

Antimicrobial prophylaxis

Thromboembolic Prophylaxis

• LMWH• UFH

• Thromboembolism-deterrent stockings

Antimicrobial Prophylaxis

• 1 hour prior to skin incision• Prolonged cases (>3 hours)• Second-generation cephalosporin and

metronidazole

Surgical Technique

VS

No NG tubes

Thoracic epidural anesthesia

Short-acting anesthetic agents

Avoidance ofSodium/fluid

overload

Short incisions/surgical technique

Warm air bodyheating in

theatre

Standard mobilization

Non-opial oralAnalgesics/NSA IDs

Prevention of nausea and vomiting

Stimulation of gut mobility

Early removal ofcatheters/drains

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Core Protocol

Thromboembolic prophylaxis

Antimicrobial prophylaxis

Standard Anesthetic Protocol

GA VS RA

Standard Anesthetic Protocol

• General anesthesia

• Short acting- agents

• Less-soluble volatile anesthetics

• The beta -blocking drugs

• Short or intermediate NMBDs

• Sugammadex

Standard Anesthetic Protocol

Preventing Hypothermia

Fluids

WET IS BEST

Fluids

TRADITIONAL

BALANCED

4-6L2-3L

2-3L 1-2L

OPERATION POST-OPERATION

2-4d

1-2d3-6kg

Positive salt and water balance sufficient to cause a 3 kg weight gain after surgery delays return of gastrointestinal function and prolongs hospital stay in patients undergoing

elective colonic resection.

Fluids

BALANCED IS BETTERWET IS BEST

Fluids

Relative Intravascular Hypovolemia

Fluid loading

Epidural Anesthesia

Vasopressor

• Transesophageal Doppler

Fluids

No NG tubes

Thoracic epidural anesthesia

Short-acting anesthetic agents

Avoidance ofSodium/fluid

overload

Warm air bodyheating in

theatre

Standard mobilization

Non-opial oralAnalgesics/NSA IDs

Prevention of nausea and vomiting

Stimulation of gut mobility

Early removal ofcatheters/drains

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Core Protocol

Nasogastric Intubation

• For evacuation air

• Increased GER

• Remove before reversal of anesthesia

• Delayed bowel function

Drainage

No NG tubes

Standard mobilization

Non-opial oralAnalgesics/NSA IDs

Prevention of nausea and vomiting

Stimulation of gut mobility

Early removal ofcatheters/drains

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Core Protocol

Preventing and Treating PONV

• Multimodal strategies– Multi antiemetic drugs– Propofol and local anesthetic-based analgesic

techniques– Minimizing opioid use– Adequate hydration– Beta-blocker or alpha2-agonist – Nonpharmacological techniques

Preventing and Treating PONV

• Risk Factors

– Female

– Non-smoker status

– Hx of PONV / Motion sickness

–Postoperative opioid use/intraoperative use

of volatile or high dose opioid technique

Preventing and Treating PONV

• Moderate risk (= 2factors) -

– Dexamethasone(induction) – or serotonin receptor antagonist

• High risk (= 3factors)– General anesthesia with propofol and remifentanil– Dexamethasone +– Serotonin receptor antagonists / droperidol

/metoclopramide

Postoperative Analgesia

• Epidural Analgesia• Acetaminophen• NSAIDS• Opioids ??

Standard mobilization

Non-opial oralAnalgesics/NSA IDs

Prevention of nausea and vomiting

Stimulation of gut mobility

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Core Protocol

Prevention Of Postoperative Ileus

Promote postoperative bowel function

Intravenous Opioid Analgesia

Laparoscopy

Oral Alviopan

Oral magnesium oxide

Midthoracic Epidural Analgesia

Fluid overloading

Postoperative Nutritional Care

Postoperative Early Enteral Nutrition

Early Mobilization

Traditional Care Day 1

ERAS Day 1

Preadmission counseling

Selective bowel-prep

Short fasting/CHO- loading

No premed

No NG tubes

Thoracic epidural anesthesia

Short-acting anesthetic agents

Avoidance ofSodium/fluid

overload

Short incisions/surgical technique

Warm air bodyheating in

theatre

Standard mobilization

Non-opial oralanalgesics/NSA IDs

Prevention of nausea and vomiting

Stimulation of gut mobility

Early removal ofcatheters/drains

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Core Protocol

Thromboembolic prophylaxis

Antimicrobial prophylaxis

GOOD JOB..GOOD OUTCOME…AND GOOD BYE…