new concepts for early patient recovery

1. +
ERAS – Role of Anesthesiologist
Presenter : Dr. Parul Gupta
Moderator : Dr. Aastha Srivastava

2. + ERAS
 Enhanced recovery after surgery – is a combination of
elements of care for elective surgery.
 Initiated by Professor Henrik Kehlet in 1993, ERAS, enhanced
recovery programs (ERPs) or “fast-track” programs have
become an important focus of perioperative management after
abdominal surgeries and recently radical cystectomy.
 ERAS protocols are multimodal perioperative care pathways
designed to achieve early recovery after surgical procedures by
maintaining pre-operative organ function and reducing
profound stress response following surgery.

3. +
 Studies have noted a fall in surgical (anastomotic leaks,
etc.), as well as non-surgical complications (nosocomial
infections, etc.) in the post-operative period.
 Successful implementation of ERAS programs reduces
duration of hospital stay.
 ERAS is associated with better quality of life outcomes
when compared to traditional care and management.

4. +
 Institutes benefit from ERAS as a structured peri-
operative program streamlines patient care.
 Early discharge means patient turnover times are
reduced and institutes may be able to serve more
patients within the available infrastructure.

5. +
 Another important component of implementation is
receiving feedback that is taken for
 Ease of delivering care
 Problems encountered by each worker within their specialty
in carrying out work designated under ERAS programs .
 Apart from these internal quality check mechanisms , an
external review or audit may be asked for if needed.
 Once changes are made the entire cycle must be re-
initiated

6. +
AIMS
OF
ERAS
To optimize pre-
operative
preparations for
surgery
Minimize the
stress response
to surgery
Avoid iatrogenic
problems such
as postoperative
ileus
Speed recovery
and return to
normal functions
Early recognition
of abnormal
recovery and
intervention if
necessary

7. +
PERIOPERATIVE
MANAGEMENT

8. +
Interventions in Enhanced Recovery After
Surgery (ERAS)

9. +
Preadmission
Preadmission nutritional
support
Cessation of smoking
Control alcohol intake
Medical optimisation
Preoperative
Evaluation and optimization
of organ function
Ensuring good nutritional
status
Improving physical fitness
Patient education
Minimal starvation
Oral carbohydrate drinks
Selective bowel prepration
PONV prophylaxis
Intraoperative
Preoperative antibiotic, acid
suppression,and prokinetic
Regional analgesia
Elective use of nasogastric
tube
Balanced fluid therapy
Temperature control
Opioid sparing anaesthesia
Minimal tissue handling
Minimum operative time
Minimal invasive surgery
Minimize drains and tubes
Postoperative
Multimodal opioid sparing
pain control
PONV prophylaxis
Easy removal of drains and
tubes
Early oral intake of fluids and
solids
Early mobilization
Post discharge follow up.

10. +
 ERAS at an institutional level requires a multi-
disciplinary team
 The core team should consist of a representative
from surgery, anesthesia and nursing
 Other important members include nutritionists,
physicians, physical & occupational therapists and
social workers

11. +
PRE OPERATIVE

12. +
1) Provide complete information about the protocol and take informed consent
2) Preanaesthesia assessment
3) Preoperative testing
4) Preoperative nutition
5) Preoperative Carbohydrate loading
6) Avoidance of mechanical bowel preparation
7) Deep vein thrombosis prophylaxis
8) Antibiotic prophylaxis
9) Prehabilitation
10) Premedication
A Sample Enhanced Recovery After
Surgery (ERAS) Protocol

13. +
Provide complete information about the
protocol and take informed consent
 Patients planned for elective surgery should be
counselled and both verbal as well as written information
should be provided.
 Information may be provided to the patient in the out-
patient clinic, the preassessment clinic or the patient’s
home.
 Information leaflets on ERAS should be produced to
facilitate patient education.

14. + Preanaesthesia assessment
 General health assesssment
 Preoperative screening
 Optimization of comorbities
 Asessment of chronic medication use as –
B-blockers, ACEIs, anti platelet drugs, anticoagulants, anti diabetic drugs,
statins etc.
 Perioperative risk assessment using ASA grading
 Assessing cardiovascular and pulmonary risk and optimization
 Education and psychological preparation of patient
 Reduces anxiety and fear
 Improves overall patient satisfaction

15. + ASA grading

16. +
Surgery related predictors for risk of perioperative cardiac
complications

17. +
Preoperative testing
 Routine screening tests are of no clinical benefit
 Unnecessary tests may cause anxiety, increase delays and
cancellations, cause potential harm stemming from false
negative or false positive results and increase cost
 Test should be guided by patient’s clinical status, comorbidity
(cardiovascular, pulmonary and renal) and invasiveness of
surgical procedure

18. +
Indications
for specific
pre-
operative
tests

19. + Preoperative nutrition
 Poor nutrition is detrimental to outcome postoperatively
especially with comorbidities and underlying disease process
as cancer.
 European Society of Parenteral and Enteral Nutrition (ESPEN)
defines severe nutritional risk as –
 Weight loss > 10% - 15% in 6months
 BMI < 18.5kg/m2
 S. albumin <30g/L
 Correction of preoperative nutritional deficiencies may
sometimes require prolonged parenteral, or combination of
parenteral and enteral nutrition depending on severity of the
problem and the patient’s gastrointestinal function

20. +
 Fasting of <8 hours before a general anaesthetic is traditional
practice before surgery. Aim is to reduce the volume and acidity
of stomach contents, thus reducing the risk of regurgitation or
aspiration.
 Recent studies have shown that even shorter (3 hour) period of
fasting after ingestion of clear fluids would be safe before
surgery.
 minimises patient thirst
 improves post-operative well being

21. +
Surgery causes
Preoperative fasting increases the metabolic stress,
hyperglycemia and insulin resistance
Preoperative carbohydrate loading

22. +
• Gluconeogenesis
• Glycogen mobilization
• Triglyercides convert
to glycerol
• Fatty acids provide the
substrates for
gluconeogensis.
• protein catabolism
• weight loss
• muscle wasting
• nitrogenous loss.
• Hypothalamus-
pituitary-adrenal axis
and mediate the
body’s subsequent
endocrine response.
• Tissue injury
• Infection
• Hypovolemia
• Hypoxia.
Stress response-
initiated by a
variety of physical
insults as-
Autonomic afferent
impulses from the
area of injury or
trauma stimulate-
Increased cortisol
levels stimulate
Adrenocorticotropic
hormone and
cortisol production-

23. +
If postoperative hyperglycaemia is controlled, mortality and
morbidity can be reduced by half.
Insulin resistance is a major variable influencing
Length of stay Poor wound healing
Increased risk of
infective complications
Also intraoperatively, there Is a relative lack of insulin and
peripheral insulin resistance occurs due to
alpha-2-adrenergic inhibition of
pancreatic B cells (facilitated by
catecholamines)
defects in the insulin
receptor/intracellular signalling
pathway.

24. +
 Carbohydrate loading involves-
 Polycal Liquid (200 ml)
 Night before surgery
 3 hours prior to surgery.
 1 carton of Polycal liquid
 494 Kcal(approximately 120 grams of carbohydrates)
 Any commercially available preparation may be used but the
formulation used should be clear and residue free.

25. +
Preoperative carbohydrate loading is also shown to be safe in non
insulin dependent diabetic patients, no adverse effects such as
hyper-glycaemia or delayed gastric emptying are shown in these
patients and thus its use is recommended in such patients also.

26. + Avoidance of mechanical bowel
preparation
 Mechanical bowel clearing has been thought to
reduce the severity of sepsis in the event of an
anastomotic leak, while, new researches have
suggested that patients undergoing colorectal
procedures, may avoid mechanical bowel
preparation without increased risk of sepsis.
 Also use of mechanical bowel preparation can result
in serious adverse events, such as
 fluid imbalance especially in elderly.

27. +
Deep vein thrombosis prophylaxis
 All patients posted for elective surgery should be started on
 Once daily low molecular weight heparin
 Given night before surgery
 continued for entire length of patient’s stay in hospital.
 Graduated compression thromboembolic deterrent stockings
(TEDs) should be used.
 Also, intraoperatively, pneumatic mechanical compression
stockings should be used.

28. + Antibiotic prophylaxis
 This is to reduce rates of wound infection after surgery.
 1st dose of antibiotics (covering both aerobic and anaerobic
organisms) should be administered
 just prior to incising the skin.
 In procedures where 2nd dose may be required-
 Procedure lasting >4 hours
 There is major blood loss (> 1500 ml)
 Those, known to be carriers of MRSA (Methicillin resistant
Staphylococcus aureus)
 prophylaxis with a glycopeptide antibiotic (Vancomycin,
Teicoplanin).

29. + Pre habilitation
 Preoprative training as muscle strengthening exercises
 Reduces fragility and disability
 Preoperative cardiovascular conditioning
 Avoidance of preoperative dehydration
 Nutritional support to boost perioperative immune function and
accelerate convalescence
 Preoperative carbohydrate loading
 Preoperative psychological preparation
 Avoid anxiety and fear

30. +
Premedications
 Avoid routine preoperative sedative hypnotics in even in
patients with significant anxiety
 Increases cognitive dysfunction
 Increases pharyngeal/laryngeal dysfunction

31. +
INTRAOPERATIVE

32. + TARGETS -
1. High inspired oxygen concentration
2. Goal directed intraoperative fluid therapy
3. Prevention of hypothermia
4. Minimal tissue handling
5. Minimum operative time
6. Minimum drains
7. Elective use of nasogastric tube and urine catheter
8. Elective use of arterial and central line
9. Opioid sparing anaesthesia
10. Regional analgesia
11. Post Operative Nausea Vomiting prophylaxis

33. +
High inspired oxygen concentrations:
 Oxygen administered during anaesthesia
 80%
 Continued for
 Minimum 6 hours postoperatively.

34. +
Molecular oxygen
Used by
polymorphonuclear
cells
Produce free
radicals
Form an important
line of defence
against pathogens
Molecular
oxygen
Synthesia of
collagen
• wound healing
• angiogenensis.
Higher tissue
oxygenation
levels in the
immediate
post-operative
period
Shown to improve
perfusion at the
anastomotic site
Reduce the risk
of surgical site
infections.

35. +
Goal directed intra-operative fluid
therapy
 Comparisons of liberal and restrictive fluid regimes suggest
that fluid overload may be detrimental, with prolonged time for-
 Return of gastrointestinal tract function
 Impaired healing
 Increased length of hospital admission.
 With early commencement of oral intake –
 Intravenous fluids can be discontinued much more quickly

36. +
Prevention of hypothermia:
Hypothermia (< 36°C) should be prevented
 Warm-air blankets
 Warming should be continued for as long as the
patient is in recovery
 If expected duration of surgery is >1hour
 warmed intravenous fluids should be used.

37. +
 Hypothermia may increase incidence of surgical site
infections as it causes
 Peripheral vasoconstriction induced hypoxia
 Altered immune response.
 Also increses-coagulopathy
 Increased cardiac morbidity
 Increased levels of circulating catecholamines with
a resultant exaggerated catabolic response

38. +
Surgical approach and incisions
Both a laparoscopic or an open approach may be used,
depending on local expertise and available resources.
 For open surgery, a lower transverse incision should be
used whenever possible.
 If a transverse incision is not possible, then a selectively
lower or upper midline incision is recommended.
 The length of the incision should be kept as short as
possible.

39. +
Avoidance of post-operative drains
and nasogastric tubes:
 Routine abdominal drains and nasogastric tubes should be
avoided.
 Nasogastric tube may be inserted temporarily during surgery
and removed at the end of the procedure if gastric
decompression is required intraoperatively.
 Abdominal drains may be painful and cause considerable
discomfort and can hinder early mobilisation.

40. +
Short duration of epidural analgesia
and local blocks :
 Epidural anesthetics are commonly used for colorectal surgery . The
aim is to reduce the dose of general anaesthetic needed and the
stress response to surgery.
 Initiated at
 Beginning of the procedure
 Continued
 maximum of 48 hours.
 Weaning from epidural analgesia should start 12 hours
postoperatively.

41. +
Epidurals
analgesia
Transversus
abdominis plane
(TAP) blocks and
other local
anaesthetic
infiltrations
Regional anaesthesia
can be used alone or
in combination with
general anaesthesia
to achieve the same
effect during
musculoskeletal
surgery.
USES-
• Directly attenuates the post-
operative stress response
• Promotes the return of gut
function (blocking the
sympathetic activity)
• Reduces post-operative opiate
usage.
• Provide post-operative
analgesia
• Reduce post-operative ileus (by
blockade of the sympathetic
nervous system)

42. +
OPIOID SPARING ANAESTHESIA
 Use of medications that have minimal post-operative hang-over
and effects on gastrointestinal motility are now used.
 Short acting anaesthetic agents and analgesics should be used
where possible, for example using fentanyl perioperatively in
preference to morphine.
 Total intravenous anaesthesia can be used, or short-acting
volatile anesthetic agents.
 Clonidine reduce cortisol secretion and benzodiazepines are
not commonly used in enhanced recovery programs due to
their sedative actions.

43. +
 Avoidance of postoperative nausea and vomiting (PONV) is
also very important. This is one of the side effects of surgery
most feared by patients and can be severely incapacitating.
 Interruption of oral analgesia caused by PONV can cause real
problems with analgesia.
POST OPERATIVE NAUSEA
VOMITING

44. +
 ERAS recommends risk stratification of patients during
surgery for PONV using the Apfel scoring system with
prophylaxis given for patients at moderate or high risk.
 For moderate risk patients ERAS recommended the use of
 Dexamethasone – induction
 5HT3 receptor antagonist as ondansetron- end of surgery
 For high risk patients
 Dexamethasone- induction
 5HT3 receptor antagonist droperidol or metoclopramide near the
end of surgery should be given.

45. +
POST OPERATIVE

46. + Avoidance of opiates and the use of
Paracetamol and non steroidal anti-
inflammatory drugs (NSAIDS)
 During post-operative period, patients should be
prescribed
 Paracetamol and NSAIDS as Ibuprofen or Diclofenac if
no contraindications to use.
 Opiates and Tramadol, should be reserved for
breakthrough pain.
 Attention should be paid whenever opoids are
administered to prevent nausea and vomiting and
regular antiemetics should be prescribed.

47. +
Early postoperative diet :
 Patients should be allowed
 Oral fluids – day of the surgery (if toleraed well)
 Oral diet – over next 24 hours
 Patients, not meeting their nutritional requirements- within 72
hours after surgery should be assessed by a dietician.
 Recent studuies have shown that- early feeding may be
beneficial
 Reducing the risks of anastomotic dehiscence
 Infections
 Reducing the duration of hospital stay.

48. + Early postoperative mobilisation:
 Patient education regarding the benefits of mobilisation is
recommended by ERAS prgrams
 Patients should be
 Made to sit in a chair with help on – evening of POD 0
 Without any help – POD 1.
 Assisted mobilisation POD 1 or POD 2
 Physiotherapy should be explained pre-operatively and then
physiotherapist help enforce mobilization plan throughout the post-
operative period.
 Immobilisation even for short duration can lead to deleterious
consequences as
 Thromboembolism,
 Loss of muscle strength
 Pulmonary atelectasis
 Worsening of pulmonary function

49. +
Restricted amount of intravenous fluid
 In post-operative phase - intravenous fluids may be required as long as
adequate oral fluid intake has not been achieved and/or epidural catheters
are still in situ.
 The ability of individuals to get rid of accumulated sodium is greatly
curtailed in the post-operative period
 Therse is no fixed point till which intravenous fluids should be stopped but
in the majority of patients, by the second post-operative day, adequate oral
fluids should be tolerated and indwelling epidural catheters removed.

50. +
Audit
 Audit meetings should be regularly organised and
should be attended by medical, nursing and other
ancillary staff.
 Clinical outcomes, including readmission rates and
compliance to the various ERAS strategies, should
be regularly audited.
 Readmission rates after ERAS implementation
should not exceed 10%.
 Results should also be disseminated using the
local IT systems such as the internet and e-mail

51. +
POST DISCHARGE
 Ensure 30 day follow up including :
 Phone call at 48hrs
 7th day clinic visit
 Any emergency visit

52. +
When ERAS is
implemented graph
is likely to show an
earlier recovery .
Preop
optimi
zation
Postop
rehabilit
ation
Intaop
maneuvers
to minimise
stress
response
ERAS
Traditional

53. +

54. +
THANK YOU!