1. 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

2. 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.

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

4. 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

5. 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’

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

7. 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

8. 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…

9. 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 ?

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

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

12. 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

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

14. Regional Techniques Epidural analgesia Peripheral Nerve Blocks
TAP block

15. 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

16. 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

17. PONV prophylaxis

18. 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

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

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

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

22. 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

23. ERAS
TEAM work

24. resource

25. 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

26. If any questions/comments ->