1. Perioperative Care for Gynecologic Oncology
Enhanced Recovery After Surgery
(ERAS)
พญ.รัตนาภรณ์ บุริมสิทธิชัย
ภาควิชาวิสัญญีวิทยา คณะแพทยศาสตร์ จุฬาลงกรณ์มหาวิทยาลัย

2. Patient’s journey in ERAS
CLINIC
PRE-OP OR
PACU
WARD
HOME
Recovery
Stress-free Anesthesia and Surgery

3. Avoid routine anxiolytics
Premedication
Optimized medical condition
Avoid routine anxiolytics
Multimodal analgesic
Cont usual medications
Pre-op counselling
Acetaminophen
NSAIDs
COX-II inhibitors
Gabapentin/Pregabalin
Nelson G, et al. Gynecol Oncol. 2016; 140:

4. ERAS key elements - Anesthesia
Pre-operative
Patient information, pre-op optimization
No prolonged fasting, preoperative carbohydrates
Analgesic premedication, avoid sedatives
Intra-operative
Short-acting, opioid-sparing, loco-regional anesthesia
Optimized fluid, normothermia, lung protective strategy
Multimodal antiemetic prophylaxis
Post-operative
Early oral intake, mobilization
Multimodal opioid-sparing oral analgesic
Early removal of IV, tubes, drains

5. Standard anesthetic technique
Short-acting anesthetic agents
Desflurane
Propofol
Opioid-sparing anesthesia
Nausea, vomiting, ileus, constipation, sedation, respiratory depression
Opioid-induced hyperalgesia/Acute opioid tolerance
Non-opioid multimodal analgesics
Loco-regional anesthesia/analgesia

6. Gabapentin/ Pregabalin
Multimodal analgesia
Acetaminophen
COX-II inhibitors
Gabapentin/ Pregabalin
Combination & Regular
i.v. acetaminophen reduced nausea when given prophylactically either
before surgery or before arrival in the postanesthesia care unit; but
not when given after the onset of pain
Prophylactically administered i.v.
acetaminophen reduced PONV, mainly mediated through superior pain control.
Alayed N, et al. Obstet Gynecol. 2014; 123:
Doleman B, et al. Reg Anesth Pain Med. 2015; 40:

7. Ketamine NMDA receptor antagonist Preventive analgesia
↓Central sensitization and opioid-induced hyperalgesia or acute opioid tolerance
Subanesthetic dose
Not increase adverse psychic effect, sedation and N/V compared to control
Attenuate central sensitization, reduce opioid tolerance
McCartney CJ, et al. Anesth Analg. 2004; 98:
Himmelseher S, et al. Anesthesiology. 2005; 102:

8. Loco-regional anesthesia/analgesia
Spinal anesthesia
0.5% bupivacaine + intrathecal morphine 0.1 mg
Local wound infiltration
Bupivacaine hydrochloride (max 2 mg/kg)
Epinephrine 1:200,000
Continuous wound infiltration (CWI)
Truncal block
Transversus abdominis plane block (TAP)
Quadratus lumborum block (QLB)
Duration plain , epin
Kalogera E, et al. Obstet Gynecol. 2016; 128:

9. Epidural analgesia Less overall pain, pain at rest, pain with activity
Fluid resuscitation and vasopressor use
Anesthesia time, time to first ambulation, pruritus, urinary retention, supplemental IV analgesia
Detract from the principle of faster recovery
Not routinely recommend epidural analgesia
Especially in ovarian cancer with substantial fluid shift resulting in hypotension  the detrimental effects on fluid management may outweigh the relative benefit of epidural and improvement in pain management
Miralpeix E, et al. Gynecol Oncol. 2016; 141:

10. Traditional Care vs ERAS Fluid management
Pre-op
Fasting
Bowel prep
Well hydrated
Intra-op
Dehydration
Fluid load
Urine output
Euvolemia
Zero-balanced
GDFT
Post-op
NPO
IV fluid
Early feeding
Discontinue IV
Outcome
Gut dysfunction
Complication
↓ileus
↓LOS
↓complication
Reduce preop thirst, hungry, anxiety and postop insulin resistance

11. Optimized peri-operative fluid management
Pre-operative
Intra-operative
Post-operative
“Well hydrated and euvolemia”
No prolonged fasting
No routine mechanical bowel preparation
Pre-operative carbohydrate drink
“Maintain central euvolemia and avoid excess Na and water”
Balanced solution
MN 1-2 ml/kg/h
No deficit, third space loss
Zero-balanced
Goal-directed fluid therapy (GDFT)
“Continue optimized fluid therapy”
Early oral intake
Discontinue IV fluid
Low sodium, low volume fluid
Post-op  What are we giving fluid for?
Miller TE, et al. Can J Anesth. 2015; 62:

12. Patient and surgical risk stratification
high
GDFT recommended
Consider postop ICU
Zero balance fluid management
GDFT not indicated
Recommend GDFT in major open surgery with large blood loss in high risk patients or SIRS responses
Surgical risk
Surgical risk  risk of blood loss and protein/fluid shift
Within ERAS protocol, pts are much less likely to be fluid responsive upon arrival in OR. Therefore, it seems likely that GDFT is unlikely cause harm or add benefit in healthy pts undergoing uneventful surgery within an ERAS pathway
Nevertheless, even within REAS protocols, a number of pts still receive preop bowel prep and have sig comorbidities and prolonged surgery with blood loss.  SV optimization will be beneficial
OPTIMISE study  GDFT in high risk pts major abd surgery  non sig trend towards decreased complications in GDFT group compared with usual care and 180-day mortality
low
low
high
Patient risk
Miller TE, et al. Can J Anaesth. 2015; 62:
Thiele RH, et al. Perioper Med. 2016; 5: 24. DOI /s

13. Postoperative nausea and vomiting (PONV)
Risk factors for PONV in adults
Female
History of PONV or motion sickness
Nonsmoking
Younger age (age < 50)
General anesthesia vs Regional anesthesia
Use of volatile anesthetics
Postoperative opioids
Duration of anesthesia
Type of surgery (cholecystectomy, laparoscopic, gynecological surgery)
Consensus guideline for management of PONV Society for Ambulatory Anesthesia
IMPACT study combination of propofol air oxygen TIVA reduce PONV risk by 25%
RCT show volatile were the primary cause of early PONV 0-2 h after surgery but did not have impact on delayed PONV 2-24 h after surgery
N2O had little impact when baseline risk for PONV is low
Evidence for the effect of type of
surgery is conflicting as reference groups differed widely and funnel plots suggested
significant publication bias.
Apfel CC, et al. Br J Anaesth. 2012; 109:
Gan TJ, et al. Anesth Analg. 2014; 118:

14. Multimodal PONV prevention
Combination of 2 or more anti-emetics
5HT3 antagonists  ondansetron 0.1 mg/kg before the end of surgery
Corticosteroids  dexamethasone 0.1 mg/kg at induction
NK-1 antagonists  aprepitant
Butyrophenones  droperidol
Antihistamines  dimenhydrinate
Anticholinergics  transdermal scopolamine
Phenothiazines  metoclopramine
Reduce baseline risk factors
Avoid emetogenic agents
Nelson G, et al. Gynecol Oncol. 2016; 140:
Gan TJ, et al. Anesth Analg. 2014; 118:

15. Lung protective ventilation strategy
Tidal volume 5-7 ml/kg
Positive end expiratory pressure (PEEP) 4-6 cmH2O
Reduce postoperative pulmonary complications
Prevent volutrauma and atelectrauma
Effect of injurious mechanical ventilation caused by both alveolar distension and repeated alveolar collapse and reopening result in ventilator-induced lung injury

16. Maintaining normothermia
Active warming, Cont. to PACU
Hypothermia
↑cortisol, catecholamines; augment stress response
Patient discomfort
↑post-op nitrogen excretion
↑cardiac event; post-op VT
↑blood loss
↑wound infection

17. Peri-operative care for gynecologic surgery
Pre-operative
Intra-operative
Post-operative
Patient education
Pre-op medical optimization
Zero balance fluid therapy ± GDFT
Early oral intake
Discontinue IV fluid
Solid food 6-8 h
Clear liquid until 2-3 h prior to surgery
PONV prophylaxis
Dexamethasone 0.1 mg/kg
Ondansetron 0.1 mg/kg
Early mobilization
Meals in chair
Out of bed
Premedication
Acetaminophen 1 g PO
Celecoxib 200 mg or Etoricoxib 120 mg PO
Pregabalin mg PO
Opoid-sparing anesthesia
Short-acting anesthetics
Multimodal analgesia
Ketamine mg/kg then 5-10 mcg/kg/min
Spinal block + morphine 0.1 mg/ PNB/ wound infiltration
Lung protective ventilation
Oral medications
Acetaminophen 500 mg q 6 h
Celecoxib 200 mg q 12 h or Etoricoxib 120 mg OD
tramadol 1 tab q 8 h
Pregabalin mg hs
Ondansetron 8 mg q 8 h
Morphine for severe pain ≥ 7
Antibiotic prophylaxis
VTE prophylaxis
No bowel preparation
Minimize tubes / drains
Early removal of tubes / drains
Pre-op carbohydrate drink
Normothermia
Post-discharge follow up
Each ER programme has to be tailored to the specific resources,
patient group and approach of the team delivering the care.

18. Thank you