ERAS what do we do differently? Annette Rebel M.D Associate Professor Associate Residency Program Director Co-Director Liver Transplant Anesthesia Department of Anesthesiology And Surgery University of Kentucky College of Medicine Lexington, KY

The information contained herein has been compiled as part of UK HealthCare’s Patient Safety Evaluation Systems, is deemed to be Patient Safety Work Product, and is privileged and confidential.

Financial Disclosures No cooperate sponsors Supported by SGEA MERS grant (2014) FAER Research in Education Grant (current) providing salary support

Objectives The participant will Understand the perioperative components of Enhanced Recovery After Surgery (ERAS) protocols Describe the impact of the different perioperative components on patient care Feel more confident in discussing the ERAS approach with colleagues and patients

ERAS: Perioperative Management Goals Conservative Fluid Management Prevention of Hypothermia Postoperative Nausea/Vomiting Short acting pharmacology Minimize Sedation Opioid sparing technique / multinodal analgesia Early Ambulation -> Early return to ‘normal life’

Pre Operatively: What do we do differently Weeks in advance 24hrs before surgery In the holding room ✔

NPO or Not? Traditional ERAS NPO guidelines Nothing after Midnight No adjustments for later starts Clear liquids (w electrolytes) until 4hrs before surgery Avoid preoperative Dehydration No need to ‘catch up’ with iv fluids

Problems ? Do patients always understand what we tell them? What is a clear liquid? Unpredictability of OR schedule Do we always identify patients with increased aspiration risk? Diabetes Obesity GERD Need for control of IV fluids – starting when IV is placed Everything over pump…

Choice of IV fluid does it make a difference? Lactated Ringer Normal Saline (0.9% naCl) More physiological Less ‘salt’ challenge But NOT perfect!!!!! More acidic No Potassium / Calcium Renal perfusion reduced More Salt -> swelling ?

Intra Operatively: What do we do differently ? Fluid management / Monitoring Normothermia PONV Prophylaxis Pain Management

Intraoperative Fluid Management Laparoscopic surgery: 1ml/kg/hr Open abdominal surgery: 3ml/kg/hr Monitoring – how do you know if the patient is normovolemic? ?

Maintenance of normothermia starts in the holding room! Hypothermia is BAD! Patient discomfort Metabolism Delayed emergence Vasoconstriction Shivering Increased oxygen consumption Wound healing impaired Coagulation impaired Bleeding risk Immune response Infection risk Young VL et al Aesthet Surg J 2006;26(5):551-71

Perioperative Pain Management Surgical plan Emphasize Alternatives to IV pharmacology Regional techniques Opioid sparing techniques NSAIDs Acetaminophen Ketorolac Gabapentin (Neurontin®) Magnesium / Lidocaine infusion

Regional Techniques Epidural analgesia Peripheral Nerve Blocks TAP block

Pro and cons for epidural analgesia Non – systemic [IV] approach Mental function unaltered Opioid sparing Be afraid of opioid side effects GI function Returns faster Better respiratory function postop Better Pain control controversial Can be supplemented if needed Ambulation Identify Contra-indication Anticoagulation Patient Refusal or unable to cooperate Assess benefit –risks for each patient Length of stay Other options Risk for hypotension Potential for decreased mobility Side effects Spinal puncture -> Headache Failure to cover surgical pain High spinal can happen

Transverse abdominis plane (TAP) block Addresses nerves supplying the anterior abdominal wall (T6-L1) Sterile Procedure, Ultrasound guided Indication: Adjunct for postop pain (abdominal/urological/gynecologic procedures); laparoscopic procedures When epidural is contraindicated or overshoot Contraindication: Infection at site Patient refusal Advantages: Single shoot (can be catheter but less durable) Covers 6-12hrs Can be done bilateral First described 2001

PONV prophylaxis

5 HT3 receptor antagonist NK-1 receptor antagonist PONV prophylaxis Propofol Corticosteroids Dexametasone 5 HT3 receptor antagonist Ondansetron Dolasetron Granisetron Dopamine receptor (R) Promethazine Droperidol Haldol Anticholinergic Scopolamine Antihistaminerg Hydroxyzine NK-1 receptor antagonist Aprepitant ® Midazolam ? Antiemetic

Post Operatively: What do we do differently? PONV Rescue Pain management Patient Management

PONV Rescue Medications Rescue medications = Dopamine receptor Haloperidol Promethazine (Phenergan ®) Metoclopromide (Reglan ®) Sedation… Post Discharge Nausea and Vomiting Scopolamine patch Aprepitant (>72hrs) Dexamethasone (>72hrs)

Ambulation: Less tubes = BETTER If NOT needed No NGT No Foley

Transition from PACU to Floor Medications from IV to po (if tolerated) Allow advancement of po intake Pain control As patient wakes up – things change….. Continue NSAIDS, minimize meds with sedative effect Ambulation

ERAS TEAM work

resource www.erassociety.org

Take Home Messages Keep IV Fluids ≈ (conservative) ‘less is more’ LR over NS Prophylaxis is better than treatment Pain PONV Move the patient ‘forward’ Minimize Sedation No reasons to stay in bed

If any questions/comments -> Email: arebe2@email.uky.edu