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

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

3. Can we cut down ?

4. 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..

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

6. 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

7. 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.

8. 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

9. 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

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

11. 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

12. 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

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

14. 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

15. 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

16. Postoperative management
Pain relief – balanced
Early enteral nutrition
Early mobilization

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Normal ----------------------ERAS
Functional status

24. 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 ??

25. Multi disciplinary Nurses Surgeons Anaesthetists Physiotherapists
Dieticians

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