ENHANCED RECOVERY AFTER SURGERY (ERAS) Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics- PhD ( physiology), IDRA

Possible factors that cause post op problems and morbidity Pain, nausea, ileus, increased cardiac demands, impaired pulmonary function. Length of stay and costs

Can we cut down ?

Fast-track’ surgery (ERAS) was pioneered by Professor Henrik Kehlet in Denmark in the early 1990s Started for colorectal surgeries – extended to others later – pelvic , gynaec and ortho Multimodal approach starting from preoperative period Hydration , pain, control of systemic illness nausea, ambulation etc..

Hydration , pain, control of systemic illness nausea, ambulation etc..

Preoperative management stabilize co-existing disease and optimize organ function before surgery. Preoperative assessment also provides an opportunity for patient education. In fast-track programmes, patients are given information about their anticipated postoperative course, analgesia, mobilization programme, and discharge Partner please – patient and medical team

Premedication Reduction of surgical stress – primary aim Beta blockers and alpha 2 agonists Beta -Blockers suppress the surgically induced increase in circulating catecholamines - therefore reduce perioperative cardiovascular morbidity. also have analgesic-sparing and anti catabolic properties, --- facilitate recovery from surgery.

Premedication Alpha 2-Agonists such as clonidine and dexmedetomidine can have opioid-sparing effects when used as premedication. There is also evidence that they may reduce perioperative myocardial ischaemia, intraoperative blood loss, postoperative nausea and vomiting

Preoperative hydration Dehydration + increased anxiety Clear fluids 2 hours prior Carbohydrate (complex) 50 – 100 gm. Not in type 1 diabetics or with high doses of insulin No colowash arbitrarily for all cases

Preoperative DVT prophylaxis – is it on ? Antibiotics Acid suppression Preoperative 300 mg gabapentin – moderate evidence

Intra operative period Intra operative management is aimed at reducing the stress response to surgery, and facilitating early feeding and mobilization after operation. THORACIC EPIDURALS short acting opioids , TIVA , short acting agents PONV prophylaxis Not to be like this

Intraoperative lidocaine infusion bolus of 100 mg prior to the incision and then 1‐2 mg/kg/hour continuous infusion is recommended for patients having laparoscopic colorectal surgery, or open colorectal surgery cases where a TEA is contraindicated

Surgical Minimally invasive surgery Transverse incisions – dermatomes – less Avoidance of routine nasogastric tubes- aspiration and ileus Drains – more pain

Excess fluids Vs restricted fluids Individualized goal directed therapy Use vasopressors for epidural hypotension BIS monitoring at 40 – 60 NMJ monitoring – no residual paralysis rocuronium and suggamadex

Say no to hypothermia Hypothermia is associated with increased wound infection, blood loss, coronary events. increases patient discomfort. Catecholamines and cortisol are also increased, -- stress response. Hypothermia (core temperature less than 36°C) should be actively prevented

Postoperative management Pain relief – balanced Early enteral nutrition Early mobilization

Pain relief – balanced Paracetomol , NSAIDs, epidurals with dilute local anesthetics and fentanyl – weaned off from 12 hours to 48 hour removal plan ( also remove foleys) Oral para + NSAIDs + oral tramadol will take over Keep the epidural - ? Segmental blocks - Affect mobilization More pain after three days – surgical consultation

Early feeds Patients should be allowed oral fluids as tolerated on the day of the surgery and built up to an oral diet over the next 24 hours Earlier thoughts – for gut surgeries – nil oral for days together improved bowel anastamosis – wrong early feeding may be beneficial in reducing the risks of anastomotic dehiscence, infections and reducing the length of stay- but be cautious in resection anastamosis

Early feeds The use of chewing gum should be encouraged starting on postoperative day 1. Each patient should chew one stick of gum, for at least 5 minutes, ≥ 3 times per day

Early mobilization Prolonged bed rest after surgery is undesirable it increases muscle loss and weakness, predisposes to venous stasis and thrombo embolism, and impairs pulmonary function Adequate pain relief

Made to sit on the day evening Move with support the next day Physiotherapist help If possible, a preoperative physio consultation and education No bedside entertainment

In emergencies Not well studied Preoperative part is nil But we can do as far as possible in the available areas Accommodate for elderly patients also

Normal ----------------------ERAS Functional status

Future directions Quality of life and patient satisfaction studies pre-operative oral Glutamine ( gut specific nutrient) supplementation reduces septic complications and length of stay after surgery. Cost benefit analyses studies – are there more readmissions ??

Multi disciplinary Nurses Surgeons Anaesthetists Physiotherapists Dieticians

Summary Thank you all ERAS – ERAA Why ? How – Pre op,Intraop,Post op Future directions Thank you all